Provider Demographics
NPI:1275668287
Name:PARK, KATHLEEN MARIE (NP MSN)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:PARK
Suffix:
Gender:F
Credentials:NP MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:455 VALLEJO ST
Mailing Address - Street 2:#308
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94133-4174
Mailing Address - Country:US
Mailing Address - Phone:415-206-3967
Mailing Address - Fax:415-206-6875
Practice Address - Street 1:1001 POTRERO AVE
Practice Address - Street 2:BLDG 93
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:415-206-3967
Practice Address - Fax:415-206-6875
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA150256163W00000X, 163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ41389Medicare UPIN