Provider Demographics
NPI:1487683074
Name:GREEN, SPARKLE (ARNP)
Entity type:Individual
Prefix:MS
First Name:SPARKLE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:GOLDIE
Other - Middle Name:SPARKLE
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:911 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:FL
Mailing Address - Zip Code:32693-3239
Mailing Address - Country:US
Mailing Address - Phone:352-463-2374
Mailing Address - Fax:352-463-2726
Practice Address - Street 1:173 NW ALBRITTON LN
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4451
Practice Address - Country:US
Practice Address - Phone:386-755-4020
Practice Address - Fax:386-752-9143
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1181972363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL033364600Medicaid
FL1181972OtherFLORIDA LICENSE NUMBER