Provider Demographics
NPI:1861291122
Name:PARK, CAROLYN MARIE
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MARIE
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 1:5438 STATE ROUTE 752
Mailing Address - Street 2:
Mailing Address - City:ASHVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43103-9464
Mailing Address - Country:US
Mailing Address - Phone:740-412-4383
Mailing Address - Fax:
Practice Address - Street 1:5438 STATE ROUTE 752
Practice Address - Street 2:
Practice Address - City:ASHVILLE
Practice Address - State:OH
Practice Address - Zip Code:43103-9464
Practice Address - Country:US
Practice Address - Phone:740-412-4383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD5046133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered