=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497388474
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELLEY ANDREA SPENCER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2020
-----------------------------------------------------
Last Update Date | 02/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1911 NE INNER LOOP
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78626-4439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-943-5151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 PECAN VISTA CV
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78626-4542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-923-5885
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 631165
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------