Provider Demographics
NPI:1205437712
Name:PARK, MARYANN T
Entity type:Individual
Prefix:
First Name:MARYANN
Middle Name:T
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:PO BOX 966
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NM
Mailing Address - Zip Code:87347-0966
Mailing Address - Country:US
Mailing Address - Phone:708-466-2244
Mailing Address - Fax:
Practice Address - Street 1:516 E NIZHONI BLVD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5748
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041470436163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse