Healthcare Provider Details

I. General information

NPI: 1396501508
Provider Name (Legal Business Name): NOELLE PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BRIAN D. ALLGOOD ARMY COMMUNITY HOSPITAL UNIT #15245
APO AP
96271
US

IV. Provider business mailing address

PSC 444 BOX 2136
APO AP
96297-0022
US

V. Phone/Fax

Practice location:
  • Phone: 315-737-1144
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86106591
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: