Provider Demographics
NPI:1639352602
Name:STARK, CHRISTAL R (RN, MSN, C-PNP)
Entity Type:Individual
Prefix:
First Name:CHRISTAL
Middle Name:R
Last Name:STARK
Suffix:
Gender:F
Credentials:RN, MSN, C-PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:400 FAIRVIEW HEIGHTS RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-9308
Mailing Address - Country:US
Mailing Address - Phone:304-872-7063
Mailing Address - Fax:304-872-7080
Practice Address - Street 1:400 FAIRVIEW HEIGHTS RD
Practice Address - Street 2:SUITE 302
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-9308
Practice Address - Country:US
Practice Address - Phone:304-872-7063
Practice Address - Fax:304-872-7080
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-12
Last Update Date:2014-08-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WV67293364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV67293OtherSTATE LICENSE