Provider Demographics
NPI:1598105694
Name:STARK, SUSAN ELIZABETH
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
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 1:5211 HIGHWAY 110
Mailing Address - Street 2:ESSENTIA HEALTH NORTHERN PINES CLINIC
Mailing Address - City:AURORA
Mailing Address - State:MN
Mailing Address - Zip Code:55705-1522
Mailing Address - Country:US
Mailing Address - Phone:218-229-3311
Mailing Address - Fax:
Practice Address - Street 1:5211 HIGHWAY 110
Practice Address - Street 2:ESSENTIA HEATLH NORTHERN PINES CLINIC
Practice Address - City:AURORA
Practice Address - State:MN
Practice Address - Zip Code:55705-1522
Practice Address - Country:US
Practice Address - Phone:218-229-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-03
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR153102-8363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1598105694Medicaid