Provider Demographics
NPI:1942955257
Name:SPARKS, CAITLIN
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:
Last Name:SPARKS
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 1:105 LISMORE DR
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-9580
Mailing Address - Country:US
Mailing Address - Phone:334-354-4047
Mailing Address - Fax:
Practice Address - Street 1:4760 WOODMERE BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-3065
Practice Address - Country:US
Practice Address - Phone:334-288-0814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-15
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant