Provider Demographics
NPI:1467617019
Name:SPARKS, EILEEN MARIE (RD, CDE)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:MARIE
Last Name:SPARKS
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14035 SW STEEPLECHASE CT
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-0418
Mailing Address - Country:US
Mailing Address - Phone:503-521-8859
Mailing Address - Fax:
Practice Address - Street 1:4855 SW WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-3460
Practice Address - Country:US
Practice Address - Phone:503-520-4853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-23
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR457133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR930798039Medicaid
OR95832421OtherDRIVER LICENSE