Provider Demographics
NPI:1255338943
Name:SPENCE, SHANNA LEIGH (MD)
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:LEIGH
Last Name:SPENCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-5207
Mailing Address - Country:US
Mailing Address - Phone:870-779-6004
Mailing Address - Fax:870-779-6100
Practice Address - Street 1:300 E 6TH ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-5207
Practice Address - Country:US
Practice Address - Phone:870-779-6004
Practice Address - Fax:870-779-6100
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC8442207Q00000X
TXK1075207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
8B4912OtherTRALBLAZERS
F69831Medicare UPIN
8B4912OtherTRALBLAZERS