Basic Information
| Provider Information | |||||||||
| NPI: | 1013568393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPARKS | ||||||||
| FirstName: | DEIDRE | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | SPARKS | ||||||||
| OtherFirstName: | DEIDRE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10 WILLOW CREEK LN APT 10109 | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724047319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704940156 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1871 FALLS BLVD N | ||||||||
| Address2: | |||||||||
| City: | WYNNE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723964026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702088989 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2019 | ||||||||
| LastUpdateDate: | 09/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4680 | AR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.