Provider Demographics
NPI:1659483071
Name:STARK, NANCY N (RN, ANP, PMHNP, APNP)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:N
Last Name:STARK
Suffix:
Gender:F
Credentials:RN, ANP, PMHNP, APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 LOUISIANA ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-2338
Mailing Address - Country:US
Mailing Address - Phone:415-290-2441
Mailing Address - Fax:
Practice Address - Street 1:6333 TELEGRAPH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1359
Practice Address - Country:US
Practice Address - Phone:510-923-1099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10258363LC1500X, 363LP2300X, 363LP0808X, 363LA2200X
CA518409363L00000X
MA184455363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA35515OtherUCSF PROVIDER NUMBER
KS201102900BMedicaid
CA077834OtherSF DPH CHN