Provider Demographics
NPI:1740431329
Name:SPARKS, VICTORIA (LMT)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:SPARKS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5121 27TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33707-5413
Mailing Address - Country:US
Mailing Address - Phone:727-821-7771
Mailing Address - Fax:
Practice Address - Street 1:1432 9TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33704-3302
Practice Address - Country:US
Practice Address - Phone:727-821-7771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA0005659174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist