Provider Demographics
NPI:1457704025
Name:STARK, KATHY JEAN (AGPCNP-BC)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:JEAN
Last Name:STARK
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 N RUTLEDGE ST
Mailing Address - Street 2:PO BOX 19627
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-6700
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-7063
Practice Address - Street 1:747 N RUTLEDGE ST
Practice Address - Street 2:5TH FLOOR
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-6700
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-7063
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014267363LG0600X, 363LA2200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209014267Medicaid
ILF400334053Medicare PIN