Provider Demographics
NPI:1255203436
Name:PARK, ANN M
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:M
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 1:510 2ND RD
Mailing Address - Street 2:
Mailing Address - City:HOLLIDAY
Mailing Address - State:TX
Mailing Address - Zip Code:76366-3640
Mailing Address - Country:US
Mailing Address - Phone:940-733-9450
Mailing Address - Fax:
Practice Address - Street 1:510 2ND RD
Practice Address - Street 2:
Practice Address - City:HOLLIDAY
Practice Address - State:TX
Practice Address - Zip Code:76366-3640
Practice Address - Country:US
Practice Address - Phone:940-733-9450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-18
Last Update Date:2025-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver