Provider Demographics
NPI:1790931665
Name:SPARKS, KRISTINA MARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIE
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 1:6764 S 950 E
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-5000
Mailing Address - Country:US
Mailing Address - Phone:801-560-4655
Mailing Address - Fax:801-944-3180
Practice Address - Street 1:110 S 9TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902
Practice Address - Country:US
Practice Address - Phone:509-573-3448
Practice Address - Fax:509-574-4481
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT368794-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered