Provider Demographics
NPI:1922559442
Name:PARK, ELLEN SAE EUN (NP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:SAE EUN
Last Name:PARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SAE EUN
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:6900 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-4148
Mailing Address - Country:US
Mailing Address - Phone:714-522-4009
Mailing Address - Fax:
Practice Address - Street 1:6900 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-4148
Practice Address - Country:US
Practice Address - Phone:714-522-4009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-19
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005023363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care