Provider Demographics
NPI:1992041859
Name:PARK, CECILIA (FNP)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:
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 1:2366 HARSHAW AVE
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-8209
Mailing Address - Country:US
Mailing Address - Phone:470-336-9635
Mailing Address - Fax:
Practice Address - Street 1:3636 SATELLITE BLVD
Practice Address - Street 2:#4A
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4590
Practice Address - Country:US
Practice Address - Phone:470-336-9635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-21
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008961111N00000X
GARN240365363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No111N00000XChiropractic ProvidersChiropractor