Provider Demographics
NPI:1811363195
Name:PARK, GRACE MIRAN (FNP)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:MIRAN
Last Name:PARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33507 9TH AVE S STE A
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6397
Mailing Address - Country:US
Mailing Address - Phone:253-874-5404
Mailing Address - Fax:253-874-8964
Practice Address - Street 1:33507 9TH AVE S STE A
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6397
Practice Address - Country:US
Practice Address - Phone:253-874-5404
Practice Address - Fax:253-874-8964
Is Sole Proprietor?:No
Enumeration Date:2015-08-20
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95002165363LF0000X
WAAP60616120363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care