Provider Demographics
NPI:1669613568
Name:SPENCER, MARY ANN NMN (CNP)
Entity type:Individual
Prefix:MS
First Name:MARY ANN
Middle Name:NMN
Last Name:SPENCER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:MS
Other - First Name:MARY ANN
Other - Middle Name:NMN
Other - Last Name:LANEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-0158
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:
Practice Address - Street 1:1235 8TH ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4219
Practice Address - Country:US
Practice Address - Phone:505-425-6788
Practice Address - Fax:505-747-7396
Is Sole Proprietor?:No
Enumeration Date:2009-03-23
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX464128163WP2201X
TXAP126564364SF0001X
NMCNP-03110364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1669613568Medicaid