Healthcare Provider Details

I. General information

NPI: 1114343985
Provider Name (Legal Business Name): KELLY STARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2014
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 E 17TH ST
AMMON ID
83406-6669
US

IV. Provider business mailing address

2705 E 17TH ST
AMMON ID
83406-6669
US

V. Phone/Fax

Practice location:
  • Phone: 208-346-7500
  • Fax: 208-346-7501
Mailing address:
  • Phone: 208-346-7500
  • Fax: 208-346-7501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-33495
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: