Healthcare Provider Details

I. General information

NPI: 1922169945
Provider Name (Legal Business Name): REBECCA EUGENIA SPARKS ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2512 HURST DR STE 120
MATTOON IL
61938-9200
US

IV. Provider business mailing address

2512 HURST DR STE 120
MATTOON IL
61938-9200
US

V. Phone/Fax

Practice location:
  • Phone: 217-258-7590
  • Fax: 217-258-3686
Mailing address:
  • Phone: 217-258-7590
  • Fax: 217-258-3686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209005418
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: