Provider Demographics
NPI:1629614136
Name:STARK, NANCI H (APRN)
Entity Type:Individual
Prefix:
First Name:NANCI
Middle Name:H
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 1:705 S KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2708
Mailing Address - Country:US
Mailing Address - Phone:708-216-8554
Mailing Address - Fax:
Practice Address - Street 1:705 S KENSINGTON AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2708
Practice Address - Country:US
Practice Address - Phone:708-216-8554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL20901978364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology