Healthcare Provider Details

I. General information

NPI: 1033260013
Provider Name (Legal Business Name): LYNN MARIE STARK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 WELDON SPRING PKWY # 300
WELDON SPRING MO
63304-9101
US

IV. Provider business mailing address

4801 WELDON SPRING PKWY # 300
WELDON SPRING MO
63304-9101
US

V. Phone/Fax

Practice location:
  • Phone: 636-949-5760
  • Fax:
Mailing address:
  • Phone: 636-949-5760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2017017205
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License Number125321
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: