Provider Demographics
NPI:1801561162
Name:PARK, NAN WILLIAMS (RN)
Entity type:Individual
Prefix:
First Name:NAN
Middle Name:WILLIAMS
Last Name:PARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 RISING SUN ARCH
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-6526
Mailing Address - Country:US
Mailing Address - Phone:757-749-3834
Mailing Address - Fax:
Practice Address - Street 1:2000 TRIDENT WAY BLDG 624
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-5599
Practice Address - Country:US
Practice Address - Phone:559-381-1279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001121383163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse