Provider Demographics
NPI:1124414602
Name:SPARKS, NICOLE A (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:SPARKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 VICTORIA PL APT B2
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-6657
Mailing Address - Country:US
Mailing Address - Phone:321-537-5306
Mailing Address - Fax:
Practice Address - Street 1:6300 HOSPITAL PKWY STE 375
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-2461
Practice Address - Country:US
Practice Address - Phone:770-771-5270
Practice Address - Fax:770-771-5279
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA390200000X
GA82173207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program