Provider Demographics
NPI:1154580637
Name:STARK, JULIE ANN
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:ANN
Last Name:STARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6427 221ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRANITE FALLS
Mailing Address - State:WA
Mailing Address - Zip Code:98252-9396
Mailing Address - Country:US
Mailing Address - Phone:360-739-2851
Mailing Address - Fax:
Practice Address - Street 1:110 SOUTH ALDER AVE
Practice Address - Street 2:
Practice Address - City:GRANITE FALLS
Practice Address - State:WA
Practice Address - Zip Code:98252
Practice Address - Country:US
Practice Address - Phone:360-739-2851
Practice Address - Fax:360-691-7264
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00011788174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist