Provider Demographics
NPI:1417564931
Name:SPARKS, ANDREA NOELLE (LPN)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:NOELLE
Last Name:SPARKS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-8053
Mailing Address - Country:US
Mailing Address - Phone:716-640-0003
Mailing Address - Fax:
Practice Address - Street 1:411 W 3RD ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-4801
Practice Address - Country:US
Practice Address - Phone:716-294-5406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301184164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse