Provider Demographics
NPI:1013568393
Name:SPARKS, DEIDRE
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:
Last Name:SPARKS
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:DEIDRE
Other - Middle Name:
Other - Last Name:SPARKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPT
Mailing Address - Street 1:10 WILLOW CREEK LN APT 10109
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-7319
Mailing Address - Country:US
Mailing Address - Phone:870-494-0156
Mailing Address - Fax:
Practice Address - Street 1:1871 FALLS BLVD N
Practice Address - Street 2:
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-4026
Practice Address - Country:US
Practice Address - Phone:870-208-8989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4680225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist