Provider Demographics
NPI:1003266370
Name:SPENCER, JUSTIN ROSS
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:ROSS
Last Name:SPENCER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2178
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41702-2178
Mailing Address - Country:US
Mailing Address - Phone:606-216-0741
Mailing Address - Fax:
Practice Address - Street 1:424 SAVANNAH RD
Practice Address - Street 2:
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-1462
Practice Address - Country:US
Practice Address - Phone:302-645-3336
Practice Address - Fax:302-645-0965
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1139290163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse