Healthcare Provider Details

I. General information

NPI: 1588181853
Provider Name (Legal Business Name): VINCENT SPENCER FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2017
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3621 MUNDY MILL RD
OAKWOOD GA
30566-3419
US

IV. Provider business mailing address

5563 ROSE RIDGE CT
FLOWERY BRANCH GA
30542-5078
US

V. Phone/Fax

Practice location:
  • Phone: 770-910-9196
  • Fax: 770-910-9197
Mailing address:
  • Phone: 678-231-0309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN234114
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: