=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730776477
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPARKS PSYCHIATRY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2020
-----------------------------------------------------
Last Update Date | 12/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15331 W BELL RD STE 212
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85374-4104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-388-2400
-----------------------------------------------------
Fax | 346-250-4317
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9898 BISSONNET ST STE 200
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77036-8025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-227-7275
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | OLUWATOYIN ISEYEMI
-----------------------------------------------------
Credential | DNP
-----------------------------------------------------
Telephone | 480-388-2400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------