Provider Demographics
NPI:1386419422
Name:SPENCER, ROXANNE M JOHNSON (CNM)
Entity type:Individual
Prefix:
First Name:ROXANNE
Middle Name:M JOHNSON
Last Name:SPENCER
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:ROXANNE
Other - Middle Name:MARIE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:222 BRISTOL WAY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-4417
Mailing Address - Country:US
Mailing Address - Phone:912-271-9699
Mailing Address - Fax:
Practice Address - Street 1:222 BRISTOL WAY
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-4417
Practice Address - Country:US
Practice Address - Phone:912-271-9699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty