Provider Demographics
NPI:1366915597
Name:STARK, AMANDA LYNN (BSN, RN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:STARK
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 S SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:WESTVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61883-1523
Mailing Address - Country:US
Mailing Address - Phone:217-213-8433
Mailing Address - Fax:
Practice Address - Street 1:404 W 9TH ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:IL
Practice Address - Zip Code:61846-1419
Practice Address - Country:US
Practice Address - Phone:217-474-6093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041411188163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse