Provider Demographics
NPI:1215632484
Name:STARK, SERENA
Entity type:Individual
Prefix:
First Name:SERENA
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:PO BOX 892
Mailing Address - Street 2:
Mailing Address - City:ANCHOR POINT
Mailing Address - State:AK
Mailing Address - Zip Code:99556-0892
Mailing Address - Country:US
Mailing Address - Phone:907-299-2319
Mailing Address - Fax:
Practice Address - Street 1:345 STERLING HWY STE 104
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7820
Practice Address - Country:US
Practice Address - Phone:907-235-7221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK102061225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist