Provider Demographics
NPI:1336282102
Name:SPARKS, PENNY (FNP)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:SPARKS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9909 PROVIDENCE FOREST LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-0216
Mailing Address - Country:US
Mailing Address - Phone:704-847-8099
Mailing Address - Fax:704-336-4709
Practice Address - Street 1:249 BILLINGSLEY RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1003
Practice Address - Country:US
Practice Address - Phone:704-336-6445
Practice Address - Fax:704-336-4709
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200026363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCZF0000071Medicaid