Provider Demographics
NPI:1376893438
Name:STARK, PATRICIA ANN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:ANN
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 1:3995 S 92ND ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53228-2100
Mailing Address - Country:US
Mailing Address - Phone:414-918-2300
Mailing Address - Fax:414-546-1850
Practice Address - Street 1:3995 S 92ND ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53228-2100
Practice Address - Country:US
Practice Address - Phone:414-918-2300
Practice Address - Fax:414-546-1850
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16242-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse