Provider Demographics
NPI:1003960055
Name:SPENCER, IVY C (ARNP)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:C
Last Name:SPENCER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:IVY
Other - Middle Name:
Other - Last Name:CROWDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 MOSSY ROCK LN SW
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-7473
Mailing Address - Country:US
Mailing Address - Phone:678-721-9830
Mailing Address - Fax:
Practice Address - Street 1:2900 PEACHTREE RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-4915
Practice Address - Country:US
Practice Address - Phone:404-424-0027
Practice Address - Fax:404-424-0028
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA123614363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P21933Medicare UPIN