Provider Demographics
NPI:1568247229
Name:STARK, ANDREA (APRN)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 N MELVIN ST
Mailing Address - Street 2:
Mailing Address - City:GIBSON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60936-1477
Mailing Address - Country:US
Mailing Address - Phone:217-784-4251
Mailing Address - Fax:
Practice Address - Street 1:227 N MARKET ST
Practice Address - Street 2:
Practice Address - City:PAXTON
Practice Address - State:IL
Practice Address - Zip Code:60957-1123
Practice Address - Country:US
Practice Address - Phone:217-379-4864
Practice Address - Fax:217-379-2604
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209028190363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily