Provider Demographics
NPI:1194727644
Name:STARK, ANDREA CHANCE (ARNP)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:CHANCE
Last Name:STARK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1920 PALM BEACH LAKES BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-3506
Mailing Address - Country:US
Mailing Address - Phone:561-509-5009
Mailing Address - Fax:561-738-1822
Practice Address - Street 1:12955 PALMS WEST DR STE 100
Practice Address - Street 2:
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-9212
Practice Address - Country:US
Practice Address - Phone:561-509-5009
Practice Address - Fax:561-798-2733
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 2587202208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL304660500Medicaid