MEDICARE: DENISE SPARKS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	06002110A	IN

General Provider Information

NPI Number	:	1881000222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE SPARKS

Provider Business Mailing Address
First Line	:	6415 BENHAM DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-8319
Country	:	US
Telephone Number	:	260-445-8770
Fax Number	:

Provider Business Practice Location Address
First Line	:	6415 BENHAM DRIVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815
Country	:	US
Telephone Number	:	260-445-8770
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2014
Last Update Date	:	07/07/2014

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Directions to “ DENISE SPARKS ” Practice Location

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