Provider Demographics
NPI:1639522683
Name:PARK, SOONGIL SHANNEN (LAC)
Entity Type:Individual
Prefix:
First Name:SOONGIL
Middle Name:SHANNEN
Last Name:PARK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10320B BALTIMORE NATIONAL PIKE
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-2128
Mailing Address - Country:US
Mailing Address - Phone:301-795-5888
Mailing Address - Fax:
Practice Address - Street 1:10320B BALTIMORE NATIONAL PIKE
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-2128
Practice Address - Country:US
Practice Address - Phone:301-795-5888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02313171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist