Provider Demographics
NPI:1588493472
Name:PARK, CATHERINE MICHELLE (FUNERAL DIRECTOR)
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:MICHELLE
Last Name:PARK
Suffix:
Gender:F
Credentials:FUNERAL DIRECTOR
Other - Prefix:
Other - First Name:CATHERINE
Other - Middle Name:MICHELLE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1097 TENA AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-1422
Mailing Address - Country:US
Mailing Address - Phone:720-280-4559
Mailing Address - Fax:
Practice Address - Street 1:611 NOBLE ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4944
Practice Address - Country:US
Practice Address - Phone:907-482-3232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK227713176P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176P00000XOther Service ProvidersFuneral Director