Provider Demographics
NPI:1992683650
Name:WILLIAMS, SPARKLE
Entity type:Individual
Prefix:
First Name:SPARKLE
Middle Name:
Last Name:WILLIAMS
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:PO BOX 410061
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-0061
Mailing Address - Country:US
Mailing Address - Phone:310-963-4930
Mailing Address - Fax:
Practice Address - Street 1:11917 VILLA DORADO DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-4703
Practice Address - Country:US
Practice Address - Phone:310-963-4930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-21
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist