Provider Demographics
NPI:1821466244
Name:SPENCER, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:SPENCER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 MILES CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:DAMARISCOTTA
Mailing Address - State:ME
Mailing Address - Zip Code:04543-4067
Mailing Address - Country:US
Mailing Address - Phone:207-563-1234
Mailing Address - Fax:
Practice Address - Street 1:24 MILES CENTER WAY
Practice Address - Street 2:
Practice Address - City:DAMARISCOTTA
Practice Address - State:ME
Practice Address - Zip Code:04543-4067
Practice Address - Country:US
Practice Address - Phone:207-563-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK121243363L00000X
TN0000020319367A00000X
MECNP211169363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731177858OtherGROUP TAX ID
OK200646580AMedicaid
OK371803OtherGROUP MEDICARE PTAN