Provider Demographics
NPI:1215184718
Name:OLLERTON, STARR PENROD (RN)
Entity Type:Individual
Prefix:
First Name:STARR
Middle Name:PENROD
Last Name:OLLERTON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:682 W SCHOOL BUS LN
Mailing Address - Street 2:
Mailing Address - City:SNOWFLAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85937-5262
Mailing Address - Country:US
Mailing Address - Phone:928-536-4156
Mailing Address - Fax:928-536-2634
Practice Address - Street 1:682 W SCHOOL BUS LN
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937-5262
Practice Address - Country:US
Practice Address - Phone:928-536-4156
Practice Address - Fax:928-536-2634
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN119093163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPRO1TECTMedicaid