Provider Demographics
NPI:1174521702
Name:STARK, CHARLOTTE JANE (FNP)
Entity type:Individual
Prefix:MRS
First Name:CHARLOTTE
Middle Name:JANE
Last Name:STARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 FAYETTEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-6523
Mailing Address - Country:US
Mailing Address - Phone:479-314-4000
Mailing Address - Fax:479-314-4050
Practice Address - Street 1:2800 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-6523
Practice Address - Country:US
Practice Address - Phone:479-314-4000
Practice Address - Fax:479-314-4050
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO80977363L00000X
AR219426363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
84-1090521008OtherROCKY MTN HEALTH PLANS
500027209OtherRAILROAD MEDICARE
P40998Medicare UPIN
84-1090521008OtherROCKY MTN HEALTH PLANS