Individual
JERRY RANDALL STARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
RN
Contact information
Practice address
848 VALLEY SPRINGS DR, SOUTHAVEN, MS 38671-4336
(901) 337-7778
Mailing address
848 VALLEY SPRINGS DR, SOUTHAVEN, MS 38671-4336
(901) 337-7778
Taxonomy
Speciality
Code
Description
License number
State
163WE0003X
Emergency Registered Nurse
Primary
R881245
MS
Other
Enumeration date
08/14/2012
Last updated
08/14/2012
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