Provider Demographics
NPI:1558684639
Name:SPIDEL, JENNIFER CLONTZ
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CLONTZ
Last Name:SPIDEL
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 1:1208 SKYWAY DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-3002
Mailing Address - Country:US
Mailing Address - Phone:704-289-2501
Mailing Address - Fax:704-225-1114
Practice Address - Street 1:1208 SKYWAY DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-3002
Practice Address - Country:US
Practice Address - Phone:704-289-2501
Practice Address - Fax:704-225-1114
Is Sole Proprietor?:No
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20337183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0905447Medicaid