Provider Demographics
NPI:1730502378
Name:SPARKS, NICOLE RENEE (LPN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:SPARKS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 N BREIEL BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-3801
Mailing Address - Country:US
Mailing Address - Phone:513-420-4500
Mailing Address - Fax:513-420-4648
Practice Address - Street 1:601 N BREIEL BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042-3801
Practice Address - Country:US
Practice Address - Phone:513-420-4500
Practice Address - Fax:513-420-4648
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH141204-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse