Provider Demographics
NPI:1114196904
Name:PARK, SUMMER L (APN)
Entity Type:Individual
Prefix:
First Name:SUMMER
Middle Name:L
Last Name:PARK
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:SUMMER
Other - Middle Name:L
Other - Last Name:ROESCHLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3909
Mailing Address - Country:US
Mailing Address - Phone:217-366-1326
Mailing Address - Fax:217-366-6106
Practice Address - Street 1:1801 WINDSOR RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-6217
Practice Address - Country:US
Practice Address - Phone:217-366-6104
Practice Address - Fax:217-366-6106
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006933363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily