Provider Demographics
NPI:1003572199
Name:SPALO, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:SPALO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10734 WALANDER NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49319-8365
Mailing Address - Country:US
Mailing Address - Phone:231-580-1634
Mailing Address - Fax:
Practice Address - Street 1:303 E KEARSLEY ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48502-1907
Practice Address - Country:US
Practice Address - Phone:231-580-1634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704261249363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care