1639265465 NPI number — DONNA JEAN SPARKS FAMILY NURSE PRACTIT

Table of content: DONNA JEAN SPARKS FAMILY NURSE PRACTIT (NPI 1639265465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639265465 NPI number — DONNA JEAN SPARKS FAMILY NURSE PRACTIT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPARKS
Provider First Name:
DONNA
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FAMILY NURSE PRACTIT
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:
1639265465
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 729
Provider Second Line Business Mailing Address:
319 FIFTH AVE.
Provider Business Mailing Address City Name:
SALTVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-496-4492
Provider Business Mailing Address Fax Number:
276-496-4839

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13168 MEADOWVIEW SQUARE
Provider Second Line Business Practice Location Address:
MEADOWVIEW COMMUNITY HEALTH
Provider Business Practice Location Address City Name:
MEADOWVIEW
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-944-3999
Provider Business Practice Location Address Fax Number:
276-944-3882
Provider Enumeration Date:
10/05/2006

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: 363LF0000X , with the licence number:  0024107429 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 0024107429 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 010062411 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".