Provider Demographics
NPI:1477098754
Name:STARK, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W HEFNER RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-6631
Mailing Address - Country:US
Mailing Address - Phone:405-896-8058
Mailing Address - Fax:855-223-1999
Practice Address - Street 1:101 W HEFNER RD STE 100
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-6631
Practice Address - Country:US
Practice Address - Phone:405-896-8058
Practice Address - Fax:855-223-1999
Is Sole Proprietor?:No
Enumeration Date:2016-12-22
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016042121363LF0000X
OK208100363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily