Healthcare Provider Details

I. General information

NPI: 1003462722
Provider Name (Legal Business Name): CAITLYN JEEIN PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2019
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7212 ORANGETHORPE AVE STE 9A
BUENA PARK CA
90621-4668
US

IV. Provider business mailing address

7212 ORANGETHORPE AVE STE 9A
BUENA PARK CA
90621-4668
US

V. Phone/Fax

Practice location:
  • Phone: 714-503-6550
  • Fax:
Mailing address:
  • Phone: 714-503-6550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number95160347
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95017087
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: