Provider Demographics
NPI:1063372803
Name:PARK, KATIE K
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:K
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5051 205TH ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11364-1043
Mailing Address - Country:US
Mailing Address - Phone:917-900-2255
Mailing Address - Fax:
Practice Address - Street 1:2811 QUEENS PLZ N FL 5
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-4172
Practice Address - Country:US
Practice Address - Phone:718-301-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-14
Last Update Date:2025-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY79718201163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty