Provider Demographics
NPI:1124561840
Name:PARK, KIERSTEN (MS, LAT, ATC)
Entity type:Individual
Prefix:MRS
First Name:KIERSTEN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2621 BOXWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-1607
Mailing Address - Country:US
Mailing Address - Phone:302-290-4067
Mailing Address - Fax:
Practice Address - Street 1:2621 BOXWOOD DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-1607
Practice Address - Country:US
Practice Address - Phone:302-290-4067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2024-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
DE2255A2300X
PA2255A2300X
NV2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program