Provider Demographics
NPI:1285674333
Name:SPARKS, REX (NP)
Entity Type:Individual
Prefix:
First Name:REX
Middle Name:
Last Name:SPARKS
Suffix:
Gender:M
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:PO BOX 634909
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:223 MADISON ST STE 103
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-3660
Practice Address - Country:US
Practice Address - Phone:615-860-0808
Practice Address - Fax:615-860-0809
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7354363LP0808X
TN109043363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4083351OtherBCBS
TN4083351OtherBCBS
TN3905507Medicare ID - Type Unspecified
TNS63671Medicare UPIN