Healthcare Provider Details

I. General information

NPI: 1851610158
Provider Name (Legal Business Name): MIRI PARK CHANG FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2010
Last Update Date: 05/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 LAKEWOOD BLVD
DOWNEY CA
90240-4020
US

IV. Provider business mailing address

10000 LAKEWOOD BLVD
DOWNEY CA
90240-4020
US

V. Phone/Fax

Practice location:
  • Phone: 562-862-3684
  • Fax:
Mailing address:
  • Phone: 562-862-3684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP 19603
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN 1230
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: