Provider Demographics
NPI:1891226296
Name:SPARKS, KELSEY ANN
Entity type:Individual
Prefix:MRS
First Name:KELSEY
Middle Name:ANN
Last Name:SPARKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 VICTORY PARKWAY
Mailing Address - Street 2:PAYOR ENROLLMENT
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1785
Mailing Address - Country:US
Mailing Address - Phone:513-585-5507
Mailing Address - Fax:
Practice Address - Street 1:9275 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45242-7779
Practice Address - Country:US
Practice Address - Phone:513-936-4510
Practice Address - Fax:513-936-4511
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-27
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.029553207R00000X
390200000X
OH35.139926207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program