Provider Demographics
NPI:1467680157
Name:THAXTON SPENCER, COLLEEN (CRNA)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:THAXTON SPENCER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 WARRENSVILLE CENTER RD
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:SHAKER HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5203
Mailing Address - Country:US
Mailing Address - Phone:216-286-6260
Mailing Address - Fax:216-286-6341
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-7334
Practice Address - Fax:216-844-3781
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.301245367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2966910Medicaid
OHP00785737OtherMEDICARE RAILROAD
OH2966910Medicaid