Provider Demographics
NPI:1568234177
Name:PARK, MALIA RENEE (RN)
Entity Type:Individual
Prefix:
First Name:MALIA
Middle Name:RENEE
Last Name:PARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:972 JACKSON CENTER POLK RD
Mailing Address - Street 2:
Mailing Address - City:STONEBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16153-3120
Mailing Address - Country:US
Mailing Address - Phone:724-699-2811
Mailing Address - Fax:
Practice Address - Street 1:740 N MAIN STREET EXT
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-1149
Practice Address - Country:US
Practice Address - Phone:814-724-3107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN527649163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health