Provider Demographics
NPI:1689140386
Name:STARK, KRISTIN NICOLE (MSN, CNM, WHNP)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:NICOLE
Last Name:STARK
Suffix:
Gender:F
Credentials:MSN, CNM, WHNP
Other - Prefix:MISS
Other - First Name:KRISTIN
Other - Middle Name:NICOLE
Other - Last Name:CHAMBERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3003 N CENTRAL AVE STE 1600
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2908
Mailing Address - Country:US
Mailing Address - Phone:602-323-3344
Mailing Address - Fax:602-323-3496
Practice Address - Street 1:6601 W THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-5700
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:623-247-9742
Is Sole Proprietor?:No
Enumeration Date:2018-10-19
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ218557367A00000X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ098184Medicaid