Provider Demographics
NPI:1366198608
Name:SPARKS, MANDY (RN, IHP)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:SPARKS
Suffix:
Gender:F
Credentials:RN, IHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8733 ORCHARD GREEN CT
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-2555
Mailing Address - Country:US
Mailing Address - Phone:240-417-5629
Mailing Address - Fax:
Practice Address - Street 1:8733 ORCHARD GREEN CT
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-2555
Practice Address - Country:US
Practice Address - Phone:240-417-5629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD171400000X
MDR209615163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No171400000XOther Service ProvidersHealth & Wellness Coach