Provider Demographics
NPI:1689709628
Name:SPARKS, GERALDINE (CRNA)
Entity Type:Individual
Prefix:
First Name:GERALDINE
Middle Name:
Last Name:SPARKS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 WARRENSVILLE CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-7024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4110 WARRENSVILLE CENTER RD
Practice Address - Street 2:
Practice Address - City:WARRENSVILLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44122-7024
Practice Address - Country:US
Practice Address - Phone:216-491-7483
Practice Address - Fax:216-491-6549
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN197164367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2734018Medicaid
OH8239082Medicare PIN