Provider Demographics
NPI:1790224509
Name:SPARKS, GAYLA
Entity Type:Individual
Prefix:
First Name:GAYLA
Middle Name:
Last Name:SPARKS
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 1:410 N. 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PORUM
Mailing Address - State:OK
Mailing Address - Zip Code:74455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:410 N. 4TH ST
Practice Address - Street 2:
Practice Address - City:PORUM
Practice Address - State:OK
Practice Address - Zip Code:74455
Practice Address - Country:US
Practice Address - Phone:918-484-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-14
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant