Healthcare Provider Details

I. General information

NPI: 1972912376
Provider Name (Legal Business Name): LAURA SPARKS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2014
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4152 WEST STATE ROAD 56
HANOVER IN
47243
US

IV. Provider business mailing address

PO BOX 1258
WAYNESBORO TN
38485-1258
US

V. Phone/Fax

Practice location:
  • Phone: 812-762-4510
  • Fax:
Mailing address:
  • Phone: 931-253-1110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71005027
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: