Healthcare Provider Details

I. General information

NPI: 1073254207
Provider Name (Legal Business Name): MICHELLE PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2022
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6015 118TH ST
JACKSONVILLE FL
32244-3703
US

IV. Provider business mailing address

PO BOX 4408
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 904-633-0610
  • Fax: 904-633-0611
Mailing address:
  • Phone: 904-633-0610
  • Fax: 904-633-0611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberOS22077
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: