Basic Information
| Provider Information | |||||||||
| NPI: | 1225313463 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STARK | ||||||||
| FirstName: | NICHOLE | ||||||||
| MiddleName: | KATRINA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40020 PUMICE DR | ||||||||
| Address2: | |||||||||
| City: | CASSEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 96016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629600812 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2640 BRESLAUER WAY | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960014246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302255200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2011 | ||||||||
| LastUpdateDate: | 04/26/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 314285-31 | WI | N | Nursing Service Providers | Licensed Practical Nurse | 164X00000X | 284320 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.