Provider Demographics
NPI:1518116029
Name:SPENCER, KIM MARIE (NP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:SPENCER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:MARIE
Other - Last Name:GOGGIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:540 DONAX AVE
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-2023
Mailing Address - Country:US
Mailing Address - Phone:619-884-1054
Mailing Address - Fax:619-543-2775
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9001
Practice Address - Country:US
Practice Address - Phone:619-543-2205
Practice Address - Fax:619-543-2775
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16518363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health