Provider Demographics
NPI:1073814950
Name:SPENCER, REVA DELORES (LPN)
Entity Type:Individual
Prefix:MS
First Name:REVA
Middle Name:DELORES
Last Name:SPENCER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5150 E 88TH ST
Mailing Address - Street 2:APT 202
Mailing Address - City:GARFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-2434
Mailing Address - Country:US
Mailing Address - Phone:216-315-4379
Mailing Address - Fax:
Practice Address - Street 1:5150 E 88TH ST
Practice Address - Street 2:APT 202
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2434
Practice Address - Country:US
Practice Address - Phone:216-315-4379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-09
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH137829164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse