Active NPI
Jerry Randall Stark, RN
- Emergency Registered Nurse
- Southaven, MS
National Provider Identifier
1447507066
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Emergency Registered Nurse
- License
- R881245
- Practice address
- 848 Valley Springs Dr
Southaven, MS 38671-4336 - Phone
- (901) 337-7778
- NPI assigned
- Aug 14, 2012
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Emergency Registered Nurse | 163WE0003X | R881245 | MS | Primary |
Addresses
Primary practice location
848 Valley Springs Dr
Southaven, MS 38671-4336
Mailing address
848 Valley Springs Dr
Southaven, MS 38671-4336
Phone (901) 337-7778
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Registered Nurse
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| R881245 | MS | MD | Emergency Registered Nurse |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1344902400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1344902400000",
"number": "1447507066",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "848 VALLEY SPRINGS DR",
"city": "SOUTHAVEN",
"state": "MS",
"postal_code": "386714336",
"telephone_number": "901-337-7778"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "848 VALLEY SPRINGS DR",
"city": "SOUTHAVEN",
"state": "MS",
"postal_code": "386714336",
"telephone_number": "901-337-7778"
}
],
"practiceLocations": [],
"basic": {
"last_name": "STARK",
"first_name": "JERRY",
"middle_name": "RANDALL",
"credential": "RN",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2012-08-14",
"last_updated": "2012-08-14",
"status": "A"
},
"taxonomies": [
{
"code": "163WE0003X",
"taxonomy_group": "",
"desc": "Registered Nurse, Emergency",
"state": "MS",
"license": "R881245",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Southaven, MS
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 14, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.