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General NPI Number Information
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NPI Number | 1104704477
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Entity Type | Individual
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Provider Name | STACEY DIANE STARK FNP
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Gender | Female
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Dates
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Enumeration Date | 08/25/2025
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Last Update Date | 09/15/2025
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Provider Practice Location Address
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Address Line | 2340 KATY LN
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City | POPLAR BLUFF
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State | MO
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Zip | 63901-2300
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Country | US
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Telephone | 573-290-3293
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Fax |
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Provider Business Mailing Address
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Address Line | 190 MERLIN DR
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City | POPLAR BLUFF
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State | MO
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Zip | 63901-8374
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Country | US
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Telephone | 573-718-9831
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 2025038960
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License Number State | MO
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