Provider Demographics
NPI:1427546852
Name:SPENCER, MARY LAUREN (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LAUREN
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 1:2905 SWEET FLAG CT
Mailing Address - Street 2:
Mailing Address - City:DARDENNE PRAIRIE
Mailing Address - State:MO
Mailing Address - Zip Code:63368-9734
Mailing Address - Country:US
Mailing Address - Phone:314-550-6695
Mailing Address - Fax:
Practice Address - Street 1:615 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-251-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-01
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008020275163WN0002X
MO2018025958363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care