Provider Demographics
NPI:1225873201
Name:STARK, JESSIE LYN (FNP-C)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:LYN
Last Name:STARK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16430 W YUMA RD
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-3102
Mailing Address - Country:US
Mailing Address - Phone:623-465-6405
Mailing Address - Fax:
Practice Address - Street 1:16430 W YUMA RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-3102
Practice Address - Country:US
Practice Address - Phone:623-465-6405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ306183363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily