Healthcare Provider Details

I. General information

NPI: 1871629055
Provider Name (Legal Business Name): MARY KATHRYN STARK RN, MS, FNP, DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY KATHRYN DERIEG RN, MS, FNP, DNP

II. Dates (important events)

Enumeration Date: 02/24/2007
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3579 FRANKLIN BLVD
EUGENE OR
97403-2356
US

IV. Provider business mailing address

3579 FRANKLIN BLVD
EUGENE OR
97403-2356
US

V. Phone/Fax

Practice location:
  • Phone: 541-344-9411
  • Fax:
Mailing address:
  • Phone: 541-344-9411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200750019NP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number704767
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number895557
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95037843
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP60171571
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: