Healthcare Provider Details

I. General information

NPI: 1003129438
Provider Name (Legal Business Name): SHANNON GAIL STARK M.A. CCC/SLP, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2010
Last Update Date: 02/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 PEARL ST W
SIDNEY NY
13838
US

IV. Provider business mailing address

205 CROCKER HILL RD
BINGHAMTON NY
13904-2513
US

V. Phone/Fax

Practice location:
  • Phone: 607-561-2021
  • Fax:
Mailing address:
  • Phone: 212-927-9706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number0106541
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number343815
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: