Provider Demographics
NPI:1164614962
Name:SPENCER, JACQUELYN ANNE (NP)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:ANNE
Last Name:SPENCER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 BUCKLEY RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-4311
Mailing Address - Country:US
Mailing Address - Phone:315-478-3311
Mailing Address - Fax:315-476-5211
Practice Address - Street 1:1304 BUCKLEY ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-4311
Practice Address - Country:US
Practice Address - Phone:315-478-3311
Practice Address - Fax:315-476-5211
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3031681363L00000X
NY3031681363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY34567AMedicare PIN
34567AMedicare PIN