Healthcare Provider Details

I. General information

NPI: 1437565801
Provider Name (Legal Business Name): HEATHER WAGNER SPENCER ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 02/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W 8TH STREET
JACKSONVILLE FL
32209
US

IV. Provider business mailing address

1833 BOULEVARD POB 5TH FLOOR
JACKSONVILLE FL
32206-4382
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-0411
  • Fax:
Mailing address:
  • Phone: 904-383-1040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP 9249214
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: