Provider Demographics
NPI:1942825336
Name:SPENCE, TYSHANAE LACOE
Entity Type:Individual
Prefix:
First Name:TYSHANAE
Middle Name:LACOE
Last Name:SPENCE
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 1:7710 W INTERSTATE 10 # 78230
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-4711
Mailing Address - Country:US
Mailing Address - Phone:737-218-6870
Mailing Address - Fax:
Practice Address - Street 1:615A W GERALD AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78221-1112
Practice Address - Country:US
Practice Address - Phone:737-218-6870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX43863689133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered