Provider Demographics
NPI:1265673263
Name:HORNBAKER-PARK, MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:HORNBAKER-PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:HORNBAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:650 JOEL DR
Mailing Address - Street 2:BLANCHFIELD ARMY COMMUNITY HOSPITAL
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5318
Mailing Address - Country:US
Mailing Address - Phone:270-412-3247
Mailing Address - Fax:
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:BLANCHFIELD ARMY COMMUNITY HOSPITAL
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223
Practice Address - Country:US
Practice Address - Phone:270-798-8106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-20
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN552372084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN