Provider Demographics
NPI:1710250493
Name:SPARKMAN, LORETTA MARGARET (PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:LORETTA
Middle Name:MARGARET
Last Name:SPARKMAN
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:PO BOX 571
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-0571
Mailing Address - Country:US
Mailing Address - Phone:866-559-8607
Mailing Address - Fax:866-559-8607
Practice Address - Street 1:313 W COUNTRY CLUB RD
Practice Address - Street 2:SUITE 5
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5804
Practice Address - Country:US
Practice Address - Phone:866-559-8607
Practice Address - Fax:866-559-8607
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02005363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNMA102670OtherMEDICARE NUMBER
NM000575565Medicaid
NM46-2684908OtherFEIN