Provider Demographics
NPI:1306127964
Name:PARK, GRACE WOODROW (NP)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:WOODROW
Last Name:PARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 SHATTUCK AVE STE 12
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-1411
Mailing Address - Country:US
Mailing Address - Phone:510-224-5354
Mailing Address - Fax:415-449-8617
Practice Address - Street 1:1801 PARK COURT PL BLDG H
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-5028
Practice Address - Country:US
Practice Address - Phone:714-881-8601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA804756163W00000X
CA95013933363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse