Provider Demographics
NPI:1417227299
Name:STARK, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:MINER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:39 ELMWOOD DR
Mailing Address - Street 2:
Mailing Address - City:APALACHIN
Mailing Address - State:NY
Mailing Address - Zip Code:13732-4302
Mailing Address - Country:US
Mailing Address - Phone:607-221-2387
Mailing Address - Fax:
Practice Address - Street 1:39 ELMWOOD DR
Practice Address - Street 2:
Practice Address - City:APALACHIN
Practice Address - State:NY
Practice Address - Zip Code:13732-4302
Practice Address - Country:US
Practice Address - Phone:607-221-2387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA632392163W00000X
NY588548163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse