Provider Demographics
NPI:1750571881
Name:STARK, ELIZABETH ANN (LMT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:STARK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4005 W 65TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-1720
Mailing Address - Country:US
Mailing Address - Phone:612-501-8477
Mailing Address - Fax:952-926-9135
Practice Address - Street 1:4005 W 65TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-1720
Practice Address - Country:US
Practice Address - Phone:612-501-8477
Practice Address - Fax:952-926-9135
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist