Healthcare Provider Details

I. General information

NPI: 1568868099
Provider Name (Legal Business Name): CHARLENE KELLEY SPARROW PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2014
Last Update Date: 02/09/2024
Certification Date: 02/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 GERMANTOWN CT STE 207
CORDOVA TN
38018-4258
US

IV. Provider business mailing address

459 VESCOVO DR
MEMPHIS TN
38117-1800
US

V. Phone/Fax

Practice location:
  • Phone: 901-878-3332
  • Fax: 901-350-7790
Mailing address:
  • Phone: 901-216-7146
  • Fax: 901-350-7790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA810627
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18326
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9411328
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number810627
License Number StateMS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier04328749
Identifier TypeMEDICAID
Identifier StateMS
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: