Provider Demographics
NPI:1871629055
Name:STARK, MARY KATHRYN (RN, MS, FNP, DNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:STARK
Suffix:
Gender:F
Credentials:RN, MS, FNP, DNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHRYN
Other - Last Name:DERIEG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, MS, FNP, DNP
Mailing Address - Street 1:2001 E MADISON ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-2959
Mailing Address - Country:US
Mailing Address - Phone:206-430-0316
Mailing Address - Fax:
Practice Address - Street 1:3668 N HARBOR LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-6914
Practice Address - Country:US
Practice Address - Phone:800-769-0045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200750019NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily