Provider Demographics
NPI:1811198401
Name:PARK, CAROL ANN (LMP AMTA)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:ANN
Last Name:PARK
Suffix:
Gender:F
Credentials:LMP AMTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5444 SOLSTICE LN
Mailing Address - Street 2:
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221
Mailing Address - Country:US
Mailing Address - Phone:360-420-0703
Mailing Address - Fax:
Practice Address - Street 1:1010 5TH ST
Practice Address - Street 2:SUITE 210
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221
Practice Address - Country:US
Practice Address - Phone:360-420-0703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015567225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist