Provider Demographics
NPI:1073875415
Name:PARKS, GEORGETTE E (TEACHER)
Entity Type:Individual
Prefix:MISS
First Name:GEORGETTE
Middle Name:E
Last Name:PARKS
Suffix:
Gender:F
Credentials:TEACHER
Other - Prefix:MRS
Other - First Name:GEORGETTE
Other - Middle Name:E
Other - Last Name:PARKSHENRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:TEACHER
Mailing Address - Street 1:482 E 167TH ST
Mailing Address - Street 2:APT#2B
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-4438
Mailing Address - Country:US
Mailing Address - Phone:917-346-2459
Mailing Address - Fax:
Practice Address - Street 1:482 E 167TH ST
Practice Address - Street 2:APT#2B
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-4438
Practice Address - Country:US
Practice Address - Phone:917-346-2459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY24231174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist