Provider Demographics
NPI:1457511123
Name:PARK, SUSAN LEE (NP, L AC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEE
Last Name:PARK
Suffix:
Gender:F
Credentials:NP, L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19745 E COLIMA RD
Mailing Address - Street 2:SUITE 12
Mailing Address - City:ROWLAND HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91748
Mailing Address - Country:US
Mailing Address - Phone:909-595-5550
Mailing Address - Fax:
Practice Address - Street 1:2700 ALTON PKWY STE 233
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606-2646
Practice Address - Country:US
Practice Address - Phone:949-475-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA10252171100000X
CA95035073363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No171100000XOther Service ProvidersAcupuncturist