Provider Demographics
NPI:1316339930
Name:SPENCE, SUZARIE VAN (FNP)
Entity type:Individual
Prefix:
First Name:SUZARIE
Middle Name:VAN
Last Name:SPENCE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SUZARIE
Other - Middle Name:
Other - Last Name:JOHN-BAPTISTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:561-499-6171
Practice Address - Street 1:6339 MACK RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-4655
Practice Address - Country:US
Practice Address - Phone:916-585-7912
Practice Address - Fax:877-479-7101
Is Sole Proprietor?:No
Enumeration Date:2015-02-19
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001965363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEFF: 6/14/16 - NORWOMedicaid
CAEFF: 6/14/16- 55THMedicaid
CAEFF: 6/14/16 - MACKMedicaid
CAEFF: 6/14/16 - MARYSMedicaid
CAEFF: 6/14/16 C HMedicaid
CACA203945 - CA140503Medicare PIN