Provider Demographics
NPI:1174092134
Name:PARKS, PATRICIA (ANNP)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:PARKS
Suffix:
Gender:F
Credentials:ANNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 SW SAINT LUCIE WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-2109
Mailing Address - Country:US
Mailing Address - Phone:571-271-2743
Mailing Address - Fax:
Practice Address - Street 1:1300 SW SAINT LUCIE WEST BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2109
Practice Address - Country:US
Practice Address - Phone:571-271-2743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-20
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024176926363LF0000X, 207Q00000X
FL11014464363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11014464OtherFLORIDA LICENSE