Provider Demographics
NPI:1164691994
Name:SPARKS, ALBERTA DIANE (RD, LD)
Entity Type:Individual
Prefix:
First Name:ALBERTA
Middle Name:DIANE
Last Name:SPARKS
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 S MAIN ST STE 300
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4923
Mailing Address - Country:US
Mailing Address - Phone:817-920-6738
Mailing Address - Fax:817-920-6743
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-920-6738
Practice Address - Fax:817-920-6743
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT04055133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered