Provider Demographics
NPI:1821828864
Name:PARK, TANYA RACHEL (CPM)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:RACHEL
Last Name:PARK
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6180 LEHMAN DR STE 103
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-3459
Mailing Address - Country:US
Mailing Address - Phone:719-229-8746
Mailing Address - Fax:719-325-0242
Practice Address - Street 1:6180 LEHMAN DR STE 103
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-3459
Practice Address - Country:US
Practice Address - Phone:719-229-8746
Practice Address - Fax:719-325-0242
Is Sole Proprietor?:No
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000237176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife