Provider Demographics
NPI:1417650896
Name:PARK, ANNE (FNP)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11401 ROBBIA DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89138-1507
Mailing Address - Country:US
Mailing Address - Phone:818-336-2192
Mailing Address - Fax:
Practice Address - Street 1:11401 ROBBIA DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89138-1507
Practice Address - Country:US
Practice Address - Phone:818-336-2192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV817289363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner