Healthcare Provider Details

I. General information

NPI: 1699584581
Provider Name (Legal Business Name): KACEY L STARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2025
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 NEUSE BLVD
NEW BERN NC
28560-3449
US

IV. Provider business mailing address

4535 DRESSLER RD NW
CANTON OH
44718-2545
US

V. Phone/Fax

Practice location:
  • Phone: 252-633-8111
  • Fax:
Mailing address:
  • Phone: 800-828-0898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WF0300X
TaxonomyFlight Registered Nurse
License Number194691
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5023171
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: