Provider Demographics
NPI:1689656910
Name:SPACKMAN, DARICE R (PAC ATC)
Entity Type:Individual
Prefix:MRS
First Name:DARICE
Middle Name:R
Last Name:SPACKMAN
Suffix:
Gender:F
Credentials:PAC ATC
Other - Prefix:MS
Other - First Name:DARICE
Other - Middle Name:R
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:330 22ND AVE N
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1844
Mailing Address - Country:US
Mailing Address - Phone:615-320-0007
Mailing Address - Fax:615-320-0009
Practice Address - Street 1:330 22ND AVE N
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1844
Practice Address - Country:US
Practice Address - Phone:615-320-0007
Practice Address - Fax:615-320-0009
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA 949363A00000X
TN949363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4166893OtherBCBS
TN4193033OtherBCBS ASSISTANT AT SURGERY
TN1504589Medicaid
TN4166893OtherBCBS
TN36705451Medicare PIN
TNP47741Medicare UPIN
TN3670546Medicare ID - Type Unspecified