Provider Demographics
NPI:1023471471
Name:PARKS, DEBORAH JEANETTE
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:JEANETTE
Last Name:PARKS
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 1:5346 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-3308
Mailing Address - Country:US
Mailing Address - Phone:314-494-6362
Mailing Address - Fax:
Practice Address - Street 1:10096 PAGE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-1433
Practice Address - Country:US
Practice Address - Phone:314-494-6362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-03
Last Update Date:2016-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0851681744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management