Provider Demographics
NPI:1598395006
Name:SPARK, SAMANTHA LEIGH BILLINGS
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEIGH BILLINGS
Last Name:SPARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:753 COUNTY ROAD 184
Mailing Address - Street 2:
Mailing Address - City:GURLEY
Mailing Address - State:AL
Mailing Address - Zip Code:35748-7121
Mailing Address - Country:US
Mailing Address - Phone:334-728-5309
Mailing Address - Fax:
Practice Address - Street 1:753 COUNTY ROAD 184
Practice Address - Street 2:
Practice Address - City:GURLEY
Practice Address - State:AL
Practice Address - Zip Code:35748-7121
Practice Address - Country:US
Practice Address - Phone:334-728-5309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS12723390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program