=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326867607
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SPENCER MICHAEL FEY FNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2024
-----------------------------------------------------
Last Update Date | 10/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 BALBRIGGAN DR
-----------------------------------------------------
City | GOOSE CREEK
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29445-5754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-834-1320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 BALBRIGGAN DR
-----------------------------------------------------
City | GOOSE CREEK
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29445-5754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-834-1320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 29477
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------