Healthcare Provider Details

I. General information

NPI: 1407349236
Provider Name (Legal Business Name): ANGELA MARIE PARK APRN-FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 11/25/2020
Certification Date: 10/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25700 SCIENCE PARK DR STE 210
BEACHWOOD OH
44122-7328
US

IV. Provider business mailing address

29055 CLEMENS RD STE A
WESTLAKE OH
44145-1135
US

V. Phone/Fax

Practice location:
  • Phone: 216-450-1613
  • Fax: 216-450-1614
Mailing address:
  • Phone: 216-450-1614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN.CNP.022853
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.022853
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: