Healthcare Provider Details

I. General information

NPI: 1497167373
Provider Name (Legal Business Name): JENNIFER MARIE SPONAUGLE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER TRAYLOR PA-C

II. Dates (important events)

Enumeration Date: 05/27/2014
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST ROACH CANCER CTR 1ST FL
LEXINGTON KY
40536-2100
US

IV. Provider business mailing address

6071W OUTER DR
DETROIT MI
48235-2624
US

V. Phone/Fax

Practice location:
  • Phone: 859-257-6006
  • Fax: 859-257-6002
Mailing address:
  • Phone: 313-966-1003
  • Fax: 313-966-1738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA3627
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601007029
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA3627
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3627
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: