Provider Demographics
NPI:1699387084
Name:PARK, KAITLYN
Entity Type:Individual
Prefix:
First Name:KAITLYN
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 1:111 TREASURE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-1810
Mailing Address - Country:US
Mailing Address - Phone:714-319-8844
Mailing Address - Fax:
Practice Address - Street 1:111 TREASURE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92602-1810
Practice Address - Country:US
Practice Address - Phone:714-319-8844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program