MEDICARE: CANDEE M SPENCE RD

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	133V00000X	Registered Dietitian	RD01461	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4101056	OTHER	TN	BCBS

General Provider Information

NPI Number	:	1598729428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CANDEE M SPENCE RD

Provider Business Mailing Address
First Line	:	1416 S ROAN ST
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-7332
Country	:	US
Telephone Number	:	423-979-6257
Fax Number	:	423-979-6285

Provider Business Practice Location Address
First Line	:	1416 S ROAN ST
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-7332
Country	:	US
Telephone Number	:	423-979-6257
Fax Number	:	423-979-6285

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

Provider Enumeration Date	:	04/17/2006
Last Update Date	:	07/08/2007

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Directions to “ CANDEE M SPENCE RD” Practice Location

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