MEDICARE: MRS. KELSEY ANN SPENCER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	4704358989	MI

General Provider Information

NPI Number	:	1073387759
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELSEY ANN SPENCER

Provider Business Mailing Address
First Line	:	11681 64TH AVE
Second Line	:
City	:	ALLENDALE
State	:	MI
Zip	:	49401-8477
Country	:	US
Telephone Number	:	616-901-8564
Fax Number	:

Provider Business Practice Location Address
First Line	:	2861 COPPERGROVE DR NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-3170
Country	:	US
Telephone Number	:	616-901-8564
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2023
Last Update Date	:	06/12/2024

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