Healthcare Provider Details

I. General information

NPI: 1376927590
Provider Name (Legal Business Name): DANIEL KEITH SPENCER AGPCNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 11/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5140 HATCHER RD
DUBLIN VA
24084-4802
US

IV. Provider business mailing address

121 PINEY VIEW LN
MOUTH OF WILSON VA
24363-3694
US

V. Phone/Fax

Practice location:
  • Phone: 540-674-5260
  • Fax: 276-783-2879
Mailing address:
  • Phone: 276-768-9058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0024172749
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number0024172749
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: