Provider Demographics
NPI:1750039814
Name:NUNNELLY-SPARKS, NANDA ABIGAIL (LAB DIRECTOR)
Entity type:Individual
Prefix:
First Name:NANDA
Middle Name:ABIGAIL
Last Name:NUNNELLY-SPARKS
Suffix:
Gender:F
Credentials:LAB DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 S PENNSYLVANIA AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-2281
Mailing Address - Country:US
Mailing Address - Phone:417-499-1525
Mailing Address - Fax:
Practice Address - Street 1:407 S PENNSYLVANIA AVE STE 202
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-2281
Practice Address - Country:US
Practice Address - Phone:417-362-6398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO26D2227808247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician