Provider Demographics
NPI:1225313463
Name:STARK, NICHOLE KATRINA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:KATRINA
Last Name:STARK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40020 PUMICE DR
Mailing Address - Street 2:
Mailing Address - City:CASSEL
Mailing Address - State:CA
Mailing Address - Zip Code:96016
Mailing Address - Country:US
Mailing Address - Phone:262-960-0812
Mailing Address - Fax:
Practice Address - Street 1:2640 BRESLAUER WAY
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-4246
Practice Address - Country:US
Practice Address - Phone:530-225-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI314285-31164W00000X
CA284320164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse