Healthcare Provider Details

I. General information

NPI: 1679909279
Provider Name (Legal Business Name): DARNELL LAMONT SPENCER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2013
Last Update Date: 09/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25501 N LAKELAND BLVD APT 205B
EUCLID OH
44132-2493
US

IV. Provider business mailing address

25501 N LAKELAND BLVD APT 205B
EUCLID OH
44132-2493
US

V. Phone/Fax

Practice location:
  • Phone: 216-288-7727
  • Fax:
Mailing address:
  • Phone: 216-288-7727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number401496680313
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: