Basic Information
Provider Information | |||||||||
NPI: | 1902880222 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PARKS | ||||||||
FirstName: | CHERYL | ||||||||
MiddleName: | ROSE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 790058 | ||||||||
Address2: |   | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631790058 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6365492380 | ||||||||
FaxNumber: | 3145695974 | ||||||||
Practice Location | |||||||||
Address1: | 45 THOMAS JOHNSON DR | ||||||||
Address2: | SUITE 207 | ||||||||
City: | FREDERICK | ||||||||
State: | MD | ||||||||
PostalCode: | 217024425 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3016943400 | ||||||||
FaxNumber: | 3016943620 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/30/2005 | ||||||||
LastUpdateDate: | 03/17/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364S00000X | RO68640 | MD | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |   |
ID Information
ID | Type | State | Issuer | Description | P00137653 | 01 | MD | MEDICARE RAILROAD (PTAN CJ8689) | OTHER | P00687678 | 01 | MD | MEDICARE RAILROAD (PTAN DD6120) | OTHER | S417-0007 | 01 | DC | CAREFIRST BCBS | OTHER | KBC1CH | 01 | MD | CAREFIRST BCBS | OTHER |