Provider Demographics
NPI:1346124864
Name:PARK, KIWON (FNP-C)
Entity type:Individual
Prefix:
First Name:KIWON
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W VALENCIA DR
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-2317
Mailing Address - Country:US
Mailing Address - Phone:858-717-2545
Mailing Address - Fax:
Practice Address - Street 1:111 W VALENCIA DR
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-2317
Practice Address - Country:US
Practice Address - Phone:858-717-2545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-05
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95036452363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner