Healthcare Provider Details

I. General information

NPI: 1326774969
Provider Name (Legal Business Name): ELLALEE SPENCER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 07/26/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MALL RD
HARRISBURG PA
17111-1202
US

IV. Provider business mailing address

143 KOKOMO AVE
HUMMELSTOWN PA
17036-1117
US

V. Phone/Fax

Practice location:
  • Phone: 717-780-6800
  • Fax:
Mailing address:
  • Phone: 717-645-3482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: