MEDICARE: MRS. REBECCA EUGENIA SPARKS ANP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209005418	IL

General Provider Information

NPI Number	:	1922169945
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. REBECCA EUGENIA SPARKS ANP

Provider Business Mailing Address
First Line	:	2512 HURST DR STE 120
Second Line	:
City	:	MATTOON
State	:	IL
Zip	:	61938-9200
Country	:	US
Telephone Number	:	217-258-7590
Fax Number	:	217-258-3686

Provider Business Practice Location Address
First Line	:	2512 HURST DR STE 120
Second Line	:
City	:	MATTOON
State	:	IL
Zip	:	61938-9200
Country	:	US
Telephone Number	:	217-258-7590
Fax Number	:	217-258-3686

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	04/26/2024

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