Provider Demographics
NPI:1275549321
Name:STARK, ROSELLE (MN, APRN, BC)
Entity Type:Individual
Prefix:MS
First Name:ROSELLE
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:MN, APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8609 SUDLEY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-8321
Mailing Address - Country:US
Mailing Address - Phone:703-577-1492
Mailing Address - Fax:703-464-0452
Practice Address - Street 1:8609 SUDLEY RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-8321
Practice Address - Country:US
Practice Address - Phone:703-577-1492
Practice Address - Fax:703-464-0452
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001162248101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010345308Medicaid