Healthcare Provider Details

I. General information

NPI: 1518976455
Provider Name (Legal Business Name): CAROLYN IJAMS SPEROS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 06/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5220 PARK AVENUE SUITE 100
MEMPHIS TN
38119-3500
US

IV. Provider business mailing address

P.O. BOX 405827
ATLANTA GA
30384-5827
US

V. Phone/Fax

Practice location:
  • Phone: 901-685-8245
  • Fax: 901-685-8248
Mailing address:
  • Phone: 870-934-5821
  • Fax: 870-934-5384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN5133
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN32647
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: