Provider Demographics
NPI:1710204078
Name:SPENCE, EDWINA FAY (NP)
Entity Type:Individual
Prefix:MRS
First Name:EDWINA
Middle Name:FAY
Last Name:SPENCE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:EDWINA
Other - Middle Name:FAY
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FAMILY NURSE PRACT
Mailing Address - Street 1:725 E STATE ST
Mailing Address - Street 2:P O BOX 740
Mailing Address - City:STERLING
Mailing Address - State:MI
Mailing Address - Zip Code:48659-9548
Mailing Address - Country:US
Mailing Address - Phone:989-654-2491
Mailing Address - Fax:989-654-2190
Practice Address - Street 1:725 E STATE ST
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:MI
Practice Address - Zip Code:48659-9548
Practice Address - Country:US
Practice Address - Phone:989-654-2491
Practice Address - Fax:989-654-2190
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006606363L00000X
MO2015001262363L00000X
MI4704318312363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100129420Medicaid
MO1710204078Medicaid
KY7100129420Medicaid