Provider Demographics
NPI:1932413838
Name:SPENCER, BREANNA ASHLEY (NP-C)
Entity Type:Individual
Prefix:MS
First Name:BREANNA
Middle Name:ASHLEY
Last Name:SPENCER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MS
Other - First Name:BREANNA
Other - Middle Name:ASHLEY
Other - Last Name:TOLERICO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1593 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5326
Mailing Address - Country:US
Mailing Address - Phone:208-262-2300
Mailing Address - Fax:208-262-2390
Practice Address - Street 1:750 N SYRINGA ST STE 190
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5275
Practice Address - Country:US
Practice Address - Phone:208-262-2328
Practice Address - Fax:208-619-5057
Is Sole Proprietor?:No
Enumeration Date:2010-08-03
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-994A363L00000X
IDNP994A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1932413838Medicaid
WA2071943Medicaid