Basic Information
| Provider Information | |||||||||
| NPI: | 1609303676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STARK | ||||||||
| FirstName: | SHAUNA | ||||||||
| MiddleName: | SUE | ||||||||
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| Credential: | DNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 925 STATE ST | ||||||||
| Address2: | |||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497702756 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 560 W MITCHELL ST STE 505 | ||||||||
| Address2: | |||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314872100 | ||||||||
| FaxNumber: | 2314871909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2017 | ||||||||
| LastUpdateDate: | 08/01/2018 | ||||||||
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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 | 363LA2100X | 4704297789 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.