Provider Demographics
NPI:1326689126
Name:STARK, DANIELLE (PA)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:
Other - Last Name:CHAMBERLAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1015 WATER WHEEL DR
Mailing Address - Street 2:
Mailing Address - City:WAUNAKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53597-8905
Mailing Address - Country:US
Mailing Address - Phone:608-669-6092
Mailing Address - Fax:
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-0001
Practice Address - Country:US
Practice Address - Phone:608-263-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-02
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4712363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical