Provider Demographics
NPI:1528040995
Name:STARK, SALLY MAGDALEN (NP)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:MAGDALEN
Last Name:STARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:110 W ENT AVENUE
Mailing Address - Street 2:
Mailing Address - City:PETERSON AFB
Mailing Address - State:CO
Mailing Address - Zip Code:80914-1595
Mailing Address - Country:US
Mailing Address - Phone:719-556-0510
Mailing Address - Fax:866-867-7926
Practice Address - Street 1:110 W ENT AVE
Practice Address - Street 2:
Practice Address - City:PETERSON AFB
Practice Address - State:CO
Practice Address - Zip Code:80914-1595
Practice Address - Country:US
Practice Address - Phone:719-556-0510
Practice Address - Fax:866-867-7926
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO57995363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health