Provider Demographics
NPI:1487439725
Name:HAYWOOD, SPARKLE
Entity type:Individual
Prefix:
First Name:SPARKLE
Middle Name:
Last Name:HAYWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1073 E 4TH ST APT 23
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-1641
Mailing Address - Country:US
Mailing Address - Phone:310-735-5406
Mailing Address - Fax:
Practice Address - Street 1:1207 E FRUIT ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4296
Practice Address - Country:US
Practice Address - Phone:714-953-9374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA690552164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse