Provider Demographics
NPI:1588891295
Name:STARK, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
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 1:67 HERITAGE LN
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-5702
Mailing Address - Country:US
Mailing Address - Phone:631-722-4636
Mailing Address - Fax:
Practice Address - Street 1:67 HERITAGE LN
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-5702
Practice Address - Country:US
Practice Address - Phone:631-722-4636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-20
Last Update Date:2009-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY345991-1163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health