Provider Demographics
NPI:1104197508
Name:SPENCE, REGAN DOLEAC (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:REGAN
Middle Name:DOLEAC
Last Name:SPENCE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:REGAN
Other - Last Name:DOLEAC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-815-0115
Mailing Address - Fax:601-984-5257
Practice Address - Street 1:350 WEST WOODROW WILSON
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213
Practice Address - Country:US
Practice Address - Phone:601-815-0115
Practice Address - Fax:601-984-5257
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR865925363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I508383Medicare PIN
MS302I507247Medicare PIN