Provider Demographics
NPI:1457033680
Name:STARK, CAITLIN ANN
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:ANN
Last Name:STARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAITLIN
Other - Middle Name:ANN
Other - Last Name:DIMAGGIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3901 RAINBOW BLVD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66160-8500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3901 RAINBOW BLVD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-8500
Practice Address - Country:US
Practice Address - Phone:913-588-1227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-149412-121163WC0200X
KS53-82458-121363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine