Provider Demographics
NPI:1174558928
Name:PARK, LINDA GRACE
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:GRACE
Last Name:PARK
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 1:915 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-2106
Mailing Address - Country:US
Mailing Address - Phone:847-931-4200
Mailing Address - Fax:
Practice Address - Street 1:733 ASCOT CT
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60194-2769
Practice Address - Country:US
Practice Address - Phone:847-519-0830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK21789Medicaid
ILK21789Medicaid
IL212443Medicare ID - Type Unspecified