Provider Demographics
NPI:1922169945
Name:SPARKS, REBECCA EUGENIA (ANP)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:EUGENIA
Last Name:SPARKS
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2512 HURST DR STE 120
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-9200
Mailing Address - Country:US
Mailing Address - Phone:217-258-7590
Mailing Address - Fax:217-258-3686
Practice Address - Street 1:2512 HURST DR STE 120
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-9200
Practice Address - Country:US
Practice Address - Phone:217-258-7590
Practice Address - Fax:217-258-3686
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005418363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily