Provider Demographics
NPI:1245088004
Name:PARK, CYNTHIA
Entity type:Individual
Prefix:
First Name:CYNTHIA
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 1:4951 CECILVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-2931
Mailing Address - Country:US
Mailing Address - Phone:310-634-7668
Mailing Address - Fax:
Practice Address - Street 1:4951 CECILVILLE AVE
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-2931
Practice Address - Country:US
Practice Address - Phone:310-634-7668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL-314623174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN