Provider Demographics
NPI:1821235268
Name:STARK, PATRICIA K (NBC-HIS)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:K
Last Name:STARK
Suffix:
Gender:F
Credentials:NBC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 4TH AVE S
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-4311
Mailing Address - Country:US
Mailing Address - Phone:563-242-7852
Mailing Address - Fax:
Practice Address - Street 1:206 4TH AVE S
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-4311
Practice Address - Country:US
Practice Address - Phone:563-242-7852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00312237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1699871947Medicaid