Provider Demographics
NPI:1376142356
Name:SPENCER, TYRONDA
Entity Type:Individual
Prefix:
First Name:TYRONDA
Middle Name:
Last Name:SPENCER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TYRONDA
Other - Middle Name:
Other - Last Name:SPENCER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1012 PROSPECT AVE E APT 824
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-1236
Mailing Address - Country:US
Mailing Address - Phone:702-271-2859
Mailing Address - Fax:
Practice Address - Street 1:1012 PROSPECT AVE E APT 824
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-1236
Practice Address - Country:US
Practice Address - Phone:702-271-2859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSJ400276Medicaid