Provider Demographics
NPI:1790249738
Name:SPENCER, JOSA RAE (NP)
Entity Type:Individual
Prefix:MRS
First Name:JOSA
Middle Name:RAE
Last Name:SPENCER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 JASON CV
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-6290
Mailing Address - Country:US
Mailing Address - Phone:601-870-8455
Mailing Address - Fax:
Practice Address - Street 1:806 JASON CV
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-6290
Practice Address - Country:US
Practice Address - Phone:601-870-8455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903076363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner