Healthcare Provider Details

I. General information

NPI: 1750819447
Provider Name (Legal Business Name): AMY MARIE STARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2017
Last Update Date: 12/22/2019
Certification Date: 12/22/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 E 104TH ST
KANSAS CITY MO
64131
US

IV. Provider business mailing address

901 E 104TH ST
KANSAS CITY MO
64131-4517
US

V. Phone/Fax

Practice location:
  • Phone: 816-769-5109
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number2005008569
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2017020422
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: