MEDICARE: SPARKLE WILLIAMS

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	133N00000X	Nutritionist

General Provider Information

NPI Number	:	1992683650
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SPARKLE WILLIAMS

Provider Business Mailing Address
First Line	:	PO BOX 410061
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-0061
Country	:	US
Telephone Number	:	310-963-4930
Fax Number	:

Provider Business Practice Location Address
First Line	:	11917 VILLA DORADO DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-4703
Country	:	US
Telephone Number	:	310-963-4930
Fax Number	:

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

Provider Enumeration Date	:	08/21/2025
Last Update Date	:	08/21/2025

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Directions to “ SPARKLE WILLIAMS ” Practice Location

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