Provider Demographics
NPI:1255598447
Name:PARK, THERESA (RN, NP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:RN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 CASTAIC AVE
Mailing Address - Street 2:
Mailing Address - City:SHELL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-1912
Mailing Address - Country:US
Mailing Address - Phone:805-295-6128
Mailing Address - Fax:
Practice Address - Street 1:415 E CHAPEL ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-4517
Practice Address - Country:US
Practice Address - Phone:805-928-5573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17824364SC1501X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SC1501XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCommunity Health/Public Health