Healthcare Provider Details

I. General information

NPI: 1013835057
Provider Name (Legal Business Name): MICHELLE PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8484 WILSHIRE BLVD STE 620
BEVERLY HILLS CA
90211-3234
US

IV. Provider business mailing address

3063 BROOKHILL ST
LA CRESCENTA CA
91214-1926
US

V. Phone/Fax

Practice location:
  • Phone: 424-428-0910
  • Fax:
Mailing address:
  • Phone: 213-820-1704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95040460
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: