Provider Demographics
NPI:1730470675
Name:SPENCER, NICOLE (DO)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:SPENCER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:4320 WORNALL RD
Mailing Address - Street 2:STE 530
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-5941
Mailing Address - Country:US
Mailing Address - Phone:816-932-4593
Mailing Address - Fax:816-932-9611
Practice Address - Street 1:4320 WORNALL RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-5941
Practice Address - Country:US
Practice Address - Phone:816-932-4593
Practice Address - Fax:816-932-9611
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2015007988208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2015007988OtherLICENSE