Healthcare Provider Details

I. General information

NPI: 1043592777
Provider Name (Legal Business Name): EMILY LOUISE SPARKS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMILY LOUISE DANNISON PA-C

II. Dates (important events)

Enumeration Date: 09/20/2011
Last Update Date: 12/27/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1471 EAST BELTLINE NE STE 201
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

1900 44TH ST SE
KENTWOOD MI
49508
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-8620
  • Fax: 616-447-7674
Mailing address:
  • Phone: 616-685-8620
  • Fax: 616-447-7674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006851
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: