Provider Demographics
NPI:1265865992
Name:SPARKS, WHITNEY BONNER (NP)
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:BONNER
Last Name:SPARKS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 E PRESIDENT AVE
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-5599
Mailing Address - Country:US
Mailing Address - Phone:662-377-4685
Mailing Address - Fax:662-377-2755
Practice Address - Street 1:26 3RD ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MS
Practice Address - Zip Code:38827-7737
Practice Address - Country:US
Practice Address - Phone:662-454-4520
Practice Address - Fax:662-454-4521
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-16
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR883463363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08781307Medicaid