Provider Demographics
NPI:1508152372
Name:PARK, HAEYOUNG
Entity Type:Individual
Prefix:
First Name:HAEYOUNG
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20315 42ND AVE
Mailing Address - Street 2:#3B
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-1828
Mailing Address - Country:US
Mailing Address - Phone:917-399-5027
Mailing Address - Fax:
Practice Address - Street 1:20315 42ND AVE
Practice Address - Street 2:#3B
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-1828
Practice Address - Country:US
Practice Address - Phone:917-399-5027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY613791163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse