Provider Demographics
NPI:1457625097
Name:PARKS, KATHLEEN BLAIR (CRNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:BLAIR
Last Name:PARKS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 N MCKENZIE ST STE 102
Mailing Address - Street 2:
Mailing Address - City:FOLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36535-2282
Mailing Address - Country:US
Mailing Address - Phone:251-949-3479
Mailing Address - Fax:251-949-3434
Practice Address - Street 1:1711 N MCKENZIE ST STE 102
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-2282
Practice Address - Country:US
Practice Address - Phone:251-952-6653
Practice Address - Fax:251-952-6651
Is Sole Proprietor?:No
Enumeration Date:2012-02-29
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-103337363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03982800Medicaid
AL146917Medicaid
AL243124Medicaid