Healthcare Provider Details

I. General information

NPI: 1972440634
Provider Name (Legal Business Name): ELLA MAE SPICKETTS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 LAKE BOONE TRL
RALEIGH NC
27607-7505
US

IV. Provider business mailing address

4848 E ROOSEVELT ST APT 2049
PHOENIX AZ
85008-7336
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-3100
  • Fax:
Mailing address:
  • Phone: 616-881-3525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-16923
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0010-16923.
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: