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General NPI Number Information
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NPI Number | 1194195834
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Entity Type | Organization
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Legal Business Name | ADVANCED PRACTICE ADULT-GERONTOLOGY
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Dates
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Enumeration Date | 10/06/2015
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Last Update Date | 10/06/2015
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Provider Practice Location Address
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Address Line | 5140 HATCHER RD FAIRVIEW HOME
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City | DUBLIN
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State | VA
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Zip | 24084-4802
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Country | US
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Telephone | 276-431-4200
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Fax |
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Provider Business Mailing Address
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Address Line | 121 PINEY VIEW LN
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City | MOUTH OF WILSON
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State | VA
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Zip | 24363-3694
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Country | US
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Telephone | 276-768-9058
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Fax | 276-783-2879
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Authorized Official
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Title or Position | OWNER
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Name | DANIEL K SPENCER
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Credential | MSN,AGPCP,BC
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Telephone | 276-768-9058
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 0017142291
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License Number State | VA
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