Provider Demographics
NPI:1134968787
Name:PARK, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20512 33RD AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-1030
Mailing Address - Country:US
Mailing Address - Phone:917-922-2270
Mailing Address - Fax:
Practice Address - Street 1:14015B SANFORD AVE FL 2
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-2557
Practice Address - Country:US
Practice Address - Phone:718-358-8288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program