Provider Demographics
NPI:1730546763
Name:SPARKS, KYLEE RAE (ATC)
Entity type:Individual
Prefix:MISS
First Name:KYLEE
Middle Name:RAE
Last Name:SPARKS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8259 HOLMARD PL
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46259-7719
Mailing Address - Country:US
Mailing Address - Phone:317-771-9492
Mailing Address - Fax:
Practice Address - Street 1:8259 HOLMARD PL
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46259-7719
Practice Address - Country:US
Practice Address - Phone:317-771-9492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-21
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
OHAT0060532255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program