Healthcare Provider Details

I. General information

NPI: 1063204469
Provider Name (Legal Business Name): IVANA SPENCER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 WILLOW LAWN DR STE 304 THE SHOPS AT WILLOW LAWN #1283
RICHMOND VA
23230-3423
US

IV. Provider business mailing address

1601 WILLOW LAWN DR STE. 304, THE SHOPS AT WILLOW LAWN #1283
RICHMOND VA
23230-3427
US

V. Phone/Fax

Practice location:
  • Phone: 804-825-2308
  • Fax: 804-964-9870
Mailing address:
  • Phone: 757-793-9483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024194447
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001284498
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: