Healthcare Provider Details

I. General information

NPI: 1417312406
Provider Name (Legal Business Name): MINA PARK AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2015
Last Update Date: 12/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8650 BELFORD AVE APT 225
LOS ANGELES CA
90045-4553
US

IV. Provider business mailing address

8650 BELFORD AVE APT 225
LOS ANGELES CA
90045-4553
US

V. Phone/Fax

Practice location:
  • Phone: 818-987-5088
  • Fax:
Mailing address:
  • Phone: 818-987-5088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95002208
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number95002208
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: