Provider Demographics
NPI:1932249786
Name:STARK, LARISSA (CRNP)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 ST PAUL PLACE
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-2102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:227 ST. PAUL PLACE
Practice Address - Street 2:6TH FLOOR
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2102
Practice Address - Country:US
Practice Address - Phone:410-332-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR140659363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health