Healthcare Provider Details

I. General information

NPI: 1790931665
Provider Name (Legal Business Name): KRISTINA MARIE SPARKS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 S 9TH AVE
YAKIMA WA
98902
US

IV. Provider business mailing address

6764 S 950 E
MIDVALE UT
84047-5000
US

V. Phone/Fax

Practice location:
  • Phone: 509-573-3448
  • Fax: 509-574-4481
Mailing address:
  • Phone: 801-560-4655
  • Fax: 801-944-3180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number368794-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: