Healthcare Provider Details

I. General information

NPI: 1124443676
Provider Name (Legal Business Name): SHANA S STARK N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2014
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 5TH ST
BROOKINGS OR
97415-9702
US

IV. Provider business mailing address

PO BOX 67250
LINCOLN NE
68506-7250
US

V. Phone/Fax

Practice location:
  • Phone: 541-412-2000
  • Fax: 541-412-2081
Mailing address:
  • Phone: 402-328-8833
  • Fax: 888-965-0959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201501818NP-PP
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number111628
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: