Basic Information
| Provider Information | |||||||||
| NPI: | 1295008795 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPARKS | ||||||||
| FirstName: | CHELSEY | ||||||||
| MiddleName: | JOHNSON | ||||||||
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| Credential: | APRN-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 E BROOKLYN ST | ||||||||
| Address2: | P O BOX 916 | ||||||||
| City: | LINDEN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370963515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315892104 | ||||||||
| FaxNumber: | 9315892513 | ||||||||
| Practice Location | |||||||||
| Address1: | 187 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DECATURVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383298078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7318522761 | ||||||||
| FaxNumber: | 7318522781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2012 | ||||||||
| LastUpdateDate: | 07/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 16496 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1528159 | 05 | TN | MEDICAID |