Provider Demographics
NPI:1205502945
Name:SPENCER, CHERYL LYNN (LPN)
Entity type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:LYNN
Last Name:SPENCER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:CHERYL
Other - Middle Name:LYNN
Other - Last Name:SPENCER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:CONCORDIA VILLAGE
Mailing Address - Street 2:4101 W. ILES
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704
Mailing Address - Country:US
Mailing Address - Phone:217-793-9429
Mailing Address - Fax:217-993-7090
Practice Address - Street 1:4101 W ILES AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-7051
Practice Address - Country:US
Practice Address - Phone:217-793-9429
Practice Address - Fax:217-993-7090
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.061514164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL043.061514Other043.061514