Healthcare Provider Details

I. General information

NPI: 1558925743
Provider Name (Legal Business Name): MICHELLE JUNGAE PARK NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 N BROAD ST
WINDER GA
30680-2153
US

IV. Provider business mailing address

8801 DAYFLOWER DR
OOLTEWAH TN
37363-6932
US

V. Phone/Fax

Practice location:
  • Phone: 770-868-1144
  • Fax: 770-868-1276
Mailing address:
  • Phone: 314-660-2620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number271767
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: