1649279530 NPI number — KIMBERLY S SPARKS CRNA

Table of content: KIMBERLY S SPARKS CRNA (NPI 1649279530)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649279530 NPI number — KIMBERLY S SPARKS CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPARKS
Provider First Name:
KIMBERLY
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649279530
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 933432
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44193-0039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-641-5072
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 CHILDRENS PLZ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45404-1815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-641-3477
Provider Business Practice Location Address Fax Number:
937-641-5410
Provider Enumeration Date:
07/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  APRN.CRNA.03816 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2044291 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200514510 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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