Provider Demographics
NPI:1790188555
Name:PARK, NATHANIA LOUISE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:NATHANIA
Middle Name:LOUISE
Last Name:PARK
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:NATHANIA
Other - Middle Name:LOUISE
Other - Last Name:PARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:821 N NELLIS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-5387
Practice Address - Country:US
Practice Address - Phone:702-438-4003
Practice Address - Fax:702-438-0555
Is Sole Proprietor?:No
Enumeration Date:2014-10-07
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN001734363LX0001X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1790188555Medicaid
NVAPRN001734OtherSTATE LICENSE