Healthcare Provider Details

I. General information

NPI: 1417241639
Provider Name (Legal Business Name): DEIDRA G PARKS CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 06/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 ESSEX ST
HACKENSACK NJ
07601-4027
US

IV. Provider business mailing address

105 WHITE POND RD
WALDWICK NJ
07463-1349
US

V. Phone/Fax

Practice location:
  • Phone: 201-646-2756
  • Fax:
Mailing address:
  • Phone: 201-447-0548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1235317298
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerNPI#

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: