Provider Demographics
NPI:1790102440
Name:STARK, LINDA
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27701 MURRIETA RD
Mailing Address - Street 2:SPACE 186
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92586-6301
Mailing Address - Country:US
Mailing Address - Phone:951-309-1485
Mailing Address - Fax:
Practice Address - Street 1:27701 MURRIETA RD
Practice Address - Street 2:SPACE 186
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92586-6301
Practice Address - Country:US
Practice Address - Phone:951-309-1485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-19
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMTRN32610163W00000X
CA572824163WC0400X
MO2006029133163WC0400X
NC231366163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health