Provider Demographics
NPI:1790115988
Name:SPARKS, SANDRA
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:
Last Name:SPARKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:E
Other - Last Name:CONN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:736 RUNNING CREEK DR
Mailing Address - Street 2:#5
Mailing Address - City:SHEPHERDSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40165-6964
Mailing Address - Country:US
Mailing Address - Phone:502-553-2508
Mailing Address - Fax:
Practice Address - Street 1:4008 PRESTON HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-1612
Practice Address - Country:US
Practice Address - Phone:502-368-1413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-25
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41602225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist