Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1053887240 |
---|---|
Provider Name | Nicolepatricia Spencer |
First Address | Fort Campbell, KY 42223-5582 |
Second Address | Fort Campbell, KY 42223-5582 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/10/2018 |
Last Update Date | 16/10/2018 |