1710250493 NPI number — MRS. LORETTA MARGARET SPARKMAN PMHNP-BC

Table of content: MRS. LORETTA MARGARET SPARKMAN PMHNP-BC (NPI 1710250493)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710250493 NPI number — MRS. LORETTA MARGARET SPARKMAN PMHNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPARKMAN
Provider First Name:
LORETTA
Provider Middle Name:
MARGARET
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PMHNP-BC
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:
1710250493
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 571
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSWELL
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88202-0571
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-559-8607
Provider Business Mailing Address Fax Number:
866-559-8607

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
313 W COUNTRY CLUB RD
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
ROSWELL
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88201-5804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-559-8607
Provider Business Practice Location Address Fax Number:
866-559-8607
Provider Enumeration Date:
02/10/2012

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: 363LP0808X , with the licence number:  CNP-02005 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NMA102670 . This is a "MEDICARE NUMBER" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 000575565 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 46-2684908 . This is a "FEIN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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