Healthcare Provider Details

I. General information

NPI: 1174097331
Provider Name (Legal Business Name): JEONG MI PAK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2019
Last Update Date: 08/02/2026
Certification Date: 08/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1053 FARMINGTON AVE # 110
FARMINGTON CT
06032-1574
US

IV. Provider business mailing address

574 WILLIS ST
BRISTOL CT
06010-7267
US

V. Phone/Fax

Practice location:
  • Phone: 860-470-4671
  • Fax: 860-808-0040
Mailing address:
  • Phone: 702-721-3541
  • Fax: 860-808-0040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number8209
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number816263
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ01120900
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11005195
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: