Provider Demographics
NPI:1174097331
Name:PAK, JEONG MI (APRN)
Entity type:Individual
Prefix:
First Name:JEONG
Middle Name:MI
Last Name:PAK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:574 WILLIS ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-7267
Mailing Address - Country:US
Mailing Address - Phone:866-333-9758
Mailing Address - Fax:
Practice Address - Street 1:11-13 SUNFLOWER AVE
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-3700
Practice Address - Country:US
Practice Address - Phone:855-505-2880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2023-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV816263363LF0000X
NJ26NJ01120900363LP0808X
FL11005195363LP0808X
CT8209363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily