Provider Demographics
NPI:1568868099
Name:SPARROW, CHARLENE KELLEY (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:KELLEY
Last Name:SPARROW
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 VESCOVO DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-1800
Mailing Address - Country:US
Mailing Address - Phone:901-216-7146
Mailing Address - Fax:901-350-7790
Practice Address - Street 1:65 GERMANTOWN CT STE 207
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-4258
Practice Address - Country:US
Practice Address - Phone:901-878-3332
Practice Address - Fax:901-350-7790
Is Sole Proprietor?:No
Enumeration Date:2014-11-11
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA810627363LF0000X
TN18326363LF0000X
FL9411328363LF0000X
MS810627363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04328749Medicaid