Provider Demographics
NPI:1518123520
Name:SPENCER, NICOLE J (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:J
Last Name:SPENCER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 W DIVISION ST STE 310
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3096
Mailing Address - Country:US
Mailing Address - Phone:312-491-5047
Mailing Address - Fax:
Practice Address - Street 1:2222 W DIVISION ST STE 310
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-3096
Practice Address - Country:US
Practice Address - Phone:312-491-5047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-30
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361264752084N0400X, 2084N0400X
IL125-050818390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program