Basic Information
| Provider Information | |||||||||
| NPI: | 1467822726 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STARK | ||||||||
| FirstName: | ROBERTA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3702 NEW VISION DR BLDG B | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602666013 | ||||||||
| FaxNumber: | 2604585831 | ||||||||
| Practice Location | |||||||||
| Address1: | 442 W HIGH ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435061681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196364517 | ||||||||
| FaxNumber: | 4196366438 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2015 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | COA13364-NP | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363L00000X | APRN.CNP.13364 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.