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General NPI Number Information
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NPI Number | 1528040995
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Entity Type | Individual
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Provider Name | SALLY MAGDALEN STARK NP
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Gender | Female
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Dates
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Enumeration Date | 11/18/2005
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Last Update Date | 03/27/2012
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Provider Practice Location Address
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Address Line | 110 W ENT AVE
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City | PETERSON AFB
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State | CO
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Zip | 80914-1595
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Country | US
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Telephone | 719-556-0510
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Fax | 866-867-7926
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Provider Business Mailing Address
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Address Line | 110 W ENT AVENUE
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City | PETERSON AFB
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State | CO
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Zip | 80914-1595
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Country | US
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Telephone | 719-556-0510
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Fax | 866-867-7926
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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 | 363LW0102X
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Taxonomy Name | Women's Health Nurse Practitioner
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License Number | 57995
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License Number State | CO
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