Provider Demographics
NPI:1659309052
Name:STARK, MERYL (FNP)
Entity Type:Individual
Prefix:MS
First Name:MERYL
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 ALLEN ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4562
Mailing Address - Country:US
Mailing Address - Phone:802-773-4256
Mailing Address - Fax:
Practice Address - Street 1:92 ALLEN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4562
Practice Address - Country:US
Practice Address - Phone:802-773-4256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0019043363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1613Medicaid
VT1613Medicaid
VTS73405Medicare UPIN
VTQX3047Medicare PIN