Healthcare Provider Details

I. General information

NPI: 1336443167
Provider Name (Legal Business Name): MS. NANCY CLEMENTINE PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2011
Last Update Date: 01/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 1 BOX 131C
EUFAULA OK
74432-9223
US

IV. Provider business mailing address

RR 1 BOX 131C
EUFAULA OK
74432-9223
US

V. Phone/Fax

Practice location:
  • Phone: 918-452-3133
  • Fax:
Mailing address:
  • Phone: 918-452-3133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: