Provider Demographics
NPI:1154888436
Name:PARKS, MARY
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:PARKS
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 1:252 EAST 8TH AVE, BLDG A.
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:NV
Mailing Address - Zip Code:89433-7127
Mailing Address - Country:US
Mailing Address - Phone:775-815-2312
Mailing Address - Fax:775-673-5084
Practice Address - Street 1:252 EAST 8TH AVE.
Practice Address - Street 2:
Practice Address - City:SUN VALLEY
Practice Address - State:NV
Practice Address - Zip Code:89433-7127
Practice Address - Country:US
Practice Address - Phone:775-815-2312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV9005058738Medicaid