Healthcare Provider Details

I. General information

NPI: 1235439100
Provider Name (Legal Business Name): CYNTHIA MICHELLE STARK LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2010
Last Update Date: 10/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 FREEDOM DR
NAPOLEON OH
43545-9038
US

IV. Provider business mailing address

1732 CROSS CREEK LN
DEFIANCE OH
43512-3650
US

V. Phone/Fax

Practice location:
  • Phone: 419-599-1660
  • Fax: 419-592-8336
Mailing address:
  • Phone: 419-784-2928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN.138864
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: