Provider Demographics
NPI:1710606496
Name:PARK, DANA NICHOLE (DPT)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:NICHOLE
Last Name:PARK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1939 RAMBLING RD
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-5934
Mailing Address - Country:US
Mailing Address - Phone:805-791-1257
Mailing Address - Fax:
Practice Address - Street 1:12501 SEAL BEACH BLVD STE 210
Practice Address - Street 2:
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-2755
Practice Address - Country:US
Practice Address - Phone:562-493-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302706225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist