Provider Demographics
NPI:1497388474
Name:SPENCER, SHELLEY ANDREA
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:ANDREA
Last Name:SPENCER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 PECAN VISTA CV
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-4542
Mailing Address - Country:US
Mailing Address - Phone:512-923-5885
Mailing Address - Fax:
Practice Address - Street 1:1911 NE INNER LOOP
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-4439
Practice Address - Country:US
Practice Address - Phone:512-943-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX631165363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner