Healthcare Provider Details

I. General information

NPI: 1467054874
Provider Name (Legal Business Name): NICOLE MARIE SPENCER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 SOUTHERN BLVD
KETTERING OH
45429-1221
US

IV. Provider business mailing address

1 PRESTIGE PL STE 550
MIAMISBURG OH
45342-6115
US

V. Phone/Fax

Practice location:
  • Phone: 937-298-4331
  • Fax:
Mailing address:
  • Phone: 937-762-1305
  • Fax: 937-522-7513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN.CNP.0026789
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: