Provider Demographics
NPI:1154704476
Name:SPENCER, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SPENCER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10710-7616
Mailing Address - Country:US
Mailing Address - Phone:914-831-4160
Mailing Address - Fax:914-831-4161
Practice Address - Street 1:73 MARKET ST
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10710-7616
Practice Address - Country:US
Practice Address - Phone:914-831-4160
Practice Address - Fax:914-831-4161
Is Sole Proprietor?:No
Enumeration Date:2015-07-06
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY339258363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily