Provider Demographics
NPI:1265626691
Name:SPARKS, TAMALA S (CRNP)
Entity type:Individual
Prefix:
First Name:TAMALA
Middle Name:S
Last Name:SPARKS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:TAMI
Other - Middle Name:SHIPMAN
Other - Last Name:SPARKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3643 LAKEFRONT DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHSIDE
Mailing Address - State:AL
Mailing Address - Zip Code:35907-0540
Mailing Address - Country:US
Mailing Address - Phone:256-613-1101
Mailing Address - Fax:
Practice Address - Street 1:1020 TUSCALOOSA AVE
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-3005
Practice Address - Country:US
Practice Address - Phone:256-546-4606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-29
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-070362363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL165014 (ANNISTON)Medicaid
AL165246Medicaid