Healthcare Provider Details

I. General information

NPI: 1104197508
Provider Name (Legal Business Name): REGAN DOLEAC SPENCE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARRIE REGAN DOLEAC NP-C

II. Dates (important events)

Enumeration Date: 01/18/2012
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 WEST WOODROW WILSON
JACKSON MS
39213
US

IV. Provider business mailing address

2500 NORTH STATE STREET
JACKSON MS
39216
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-0115
  • Fax: 601-984-5257
Mailing address:
  • Phone: 601-815-0115
  • Fax: 601-984-5257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR865925
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: