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General NPI Number Information
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NPI Number | 1003129438
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Entity Type | Individual
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Provider Name | SHANNON GAIL STARK M.A. CCC/SLP, NP-C
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Gender | Female
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Dates
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Enumeration Date | 07/14/2010
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Last Update Date | 02/04/2019
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Provider Practice Location Address
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Address Line | 39 PEARL ST W
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City | SIDNEY
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State | NY
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Zip | 13838
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Country | US
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Telephone | 607-561-2021
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Fax |
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Provider Business Mailing Address
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Address Line | 205 CROCKER HILL RD
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City | BINGHAMTON
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State | NY
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Zip | 13904-2513
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Country | US
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Telephone | 212-927-9706
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 0106541
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 343815
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License Number State | NY
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