Provider Demographics
NPI:1679909279
Name:SPENCER, DARNELL LAMONT
Entity Type:Individual
Prefix:
First Name:DARNELL
Middle Name:LAMONT
Last Name:SPENCER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25501 N LAKELAND BLVD APT 205B
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44132-2493
Mailing Address - Country:US
Mailing Address - Phone:216-288-7727
Mailing Address - Fax:
Practice Address - Street 1:25501 N LAKELAND BLVD APT 205B
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44132-2493
Practice Address - Country:US
Practice Address - Phone:216-288-7727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401496680313376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide