Provider Demographics
NPI:1184279325
Name:SPARKS, SARA NICOLE
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:NICOLE
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 1:202 W STEENHOEK ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50228-8812
Mailing Address - Country:US
Mailing Address - Phone:712-210-5167
Mailing Address - Fax:
Practice Address - Street 1:812 UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-1902
Practice Address - Country:US
Practice Address - Phone:877-462-3687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1087412255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1982665AMedicaid