Provider Demographics
NPI:1730645763
Name:STARK, SHANNON LYNN (NP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYNN
Last Name:STARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11261 E RALEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-4084
Mailing Address - Country:US
Mailing Address - Phone:480-353-6758
Mailing Address - Fax:
Practice Address - Street 1:2735 E MAIN ST STE 2&3
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-9269
Practice Address - Country:US
Practice Address - Phone:480-867-1722
Practice Address - Fax:480-867-1709
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ222543363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily