Healthcare Provider Details

I. General information

NPI: 1003108564
Provider Name (Legal Business Name): KRISTIN SPARKS REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2011
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 18 SOLDIER CREEK ROAD
ROSEBUD SD
57570
US

IV. Provider business mailing address

HWY 18 SOLDIER CREEK ROAD
ROSEBUD SD
57570
US

V. Phone/Fax

Practice location:
  • Phone: 605-747-2231
  • Fax: 605-747-2216
Mailing address:
  • Phone: 605-747-2231
  • Fax: 605-747-2216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR885216
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: