Healthcare Provider Details

I. General information

NPI: 1790102440
Provider Name (Legal Business Name): LINDA STARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2014
Last Update Date: 03/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27701 MURRIETA RD SPACE 186
MENIFEE CA
92586-6301
US

IV. Provider business mailing address

27701 MURRIETA RD SPACE 186
MENIFEE CA
92586-6301
US

V. Phone/Fax

Practice location:
  • Phone: 951-309-1485
  • Fax:
Mailing address:
  • Phone: 951-309-1485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberMTRN32610
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number572824
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number2006029133
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number231366
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: