Healthcare Provider Details

I. General information

NPI: 1306127964
Provider Name (Legal Business Name): GRACE WOODROW PARK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2011
Last Update Date: 07/28/2022
Certification Date: 07/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 PARK COURT PL BLDG H
SANTA ANA CA
92701-5028
US

IV. Provider business mailing address

1400 SHATTUCK AVE STE 12
BERKELEY CA
94709-1411
US

V. Phone/Fax

Practice location:
  • Phone: 714-881-8601
  • Fax:
Mailing address:
  • Phone: 510-224-5354
  • Fax: 415-449-8617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95013933
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number804756
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: