Provider Demographics
NPI:1033508213
Name:POTTER, SPARKLE MAHOGANY (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:SPARKLE
Middle Name:MAHOGANY
Last Name:POTTER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:SPARKLE
Other - Middle Name:MAHOGANY
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:77 NEALY AVE
Mailing Address - Street 2:
Mailing Address - City:LANGLEY AFB
Mailing Address - State:VA
Mailing Address - Zip Code:23665-2040
Mailing Address - Country:US
Mailing Address - Phone:757-764-6015
Mailing Address - Fax:
Practice Address - Street 1:77 NEALY AVE
Practice Address - Street 2:
Practice Address - City:LANGLEY AFB
Practice Address - State:VA
Practice Address - Zip Code:23665-2040
Practice Address - Country:US
Practice Address - Phone:757-764-6015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-12
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024182190367500000X
NVCRNA000473367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered