Healthcare Provider Details

I. General information

NPI: 1033072830
Provider Name (Legal Business Name): DANIELLE DESTINY SPENCER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 ERIE BLVD W
SYRACUSE NY
13204-2445
US

IV. Provider business mailing address

620 ERIE BLVD W
SYRACUSE NY
13204-2445
US

V. Phone/Fax

Practice location:
  • Phone: 315-551-2985
  • Fax:
Mailing address:
  • Phone: 315-551-2985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberN05725-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: