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General NPI Number Information
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NPI Number | 1669983375
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Entity Type | Individual
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Provider Name | ALYSA MAREN SPARKMAN-MENDOZA
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Gender | Female
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Dates
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Enumeration Date | 10/20/2017
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Last Update Date | 10/20/2017
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Provider Practice Location Address
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Address Line | 1904 RICHLAND AVE
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City | CERES
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State | CA
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Zip | 95307-4562
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Country | US
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Telephone | 209-300-8800
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Fax |
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Provider Business Mailing Address
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Address Line | 2283 WHISPER WAY
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City | ATWATER
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State | CA
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Zip | 95301-2563
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WP0808X
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Taxonomy Name | Psychiatric/Mental Health Registered Nurse
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License Number | 820878
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License Number State | CA
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