Provider Demographics
NPI:1356479380
Name:PARK, SANDRA LUCILLE (ARNP)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:LUCILLE
Last Name:PARK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 929
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32572-0929
Mailing Address - Country:US
Mailing Address - Phone:850-983-5200
Mailing Address - Fax:850-983-5215
Practice Address - Street 1:5527 STEWART ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-4303
Practice Address - Country:US
Practice Address - Phone:850-983-5200
Practice Address - Fax:850-983-5215
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1805132363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health