Basic Information
| Provider Information | |||||||||
| NPI: | 1528040995 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STARK | ||||||||
| FirstName: | SALLY | ||||||||
| MiddleName: | MAGDALEN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 W ENT AVENUE | ||||||||
| Address2: | |||||||||
| City: | PETERSON AFB | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809141595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195560510 | ||||||||
| FaxNumber: | 8668677926 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 W ENT AVE | ||||||||
| Address2: | |||||||||
| City: | PETERSON AFB | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809141595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195560510 | ||||||||
| FaxNumber: | 8668677926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 03/27/2012 | ||||||||
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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 | 57995 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
No ID Information.