Healthcare Provider Details

I. General information

NPI: 1689537573
Provider Name (Legal Business Name): STEPHANIE LORRAINE SPARKS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4655 CROFTSHIRE DR
DAYTON OH
45440-1704
US

IV. Provider business mailing address

4606 CROFTSHIRE DR
DAYTON OH
45440-1705
US

V. Phone/Fax

Practice location:
  • Phone: 937-956-4464
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License NumberUM206407
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: