Provider Demographics
NPI:1588684740
Name:SPENCER, KIMBERLY A (CNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:SPENCER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:1049 WESTERN AVENUE
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-0188
Mailing Address - Country:US
Mailing Address - Phone:740-773-4366
Mailing Address - Fax:740-773-7855
Practice Address - Street 1:25716 WILSON ST
Practice Address - Street 2:
Practice Address - City:COOLVILLE
Practice Address - State:OH
Practice Address - Zip Code:45723-8153
Practice Address - Country:US
Practice Address - Phone:740-846-0008
Practice Address - Fax:740-846-0098
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP07474363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2462446Medicaid
OHSPNP14772Medicare ID - Type Unspecified
OHH103440Medicare PIN
OHQ05375Medicare UPIN
OH2462446Medicaid