Provider Demographics
NPI:1790371037
Name:PARK, KATHERINE SUMIN (RN)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:SUMIN
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 1:3075 ADELINE ST STE 280
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-2580
Mailing Address - Country:US
Mailing Address - Phone:510-981-4100
Mailing Address - Fax:
Practice Address - Street 1:3075 ADELINE ST STE 280
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703-2580
Practice Address - Country:US
Practice Address - Phone:510-981-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-20
Last Update Date:2020-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95111575163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse