Doctor Name: | MS. SALLY MAGDALEN STARK |
NPI Number: | 1528040995 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | NP |
License Number: | 57995 |
Business Practice Address: | 110 W Ent Ave Peterson Afb, CO - 809141595 |
Business Phone Number: | 7195560510 |
Business Fax Number: | 8668677926 |
Mailing Address: | 110 W Ent Avenue, PETERSON AFB |
State: | CO |
Postal Code: | 809141595 |
Phone Number: | 7195560510 |
Fax Number: | 8668677926 |
NPI Enumeration Date: | 11/18/2005 |
NPI Last Update Date: | 03/27/2012 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363LW0102X |
License Number: | 57995 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | CO |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Nurse Practitioner |
Taxonomy Specialization: | Women's Health |
Taxonomy Definition: |