Provider Demographics
NPI:1417761891
Name:SPENCER, AMY JO (RN)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:JO
Last Name:SPENCER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4275 PARKER RD
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3725
Mailing Address - Country:US
Mailing Address - Phone:810-841-8791
Mailing Address - Fax:
Practice Address - Street 1:4275 PARKER RD
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3725
Practice Address - Country:US
Practice Address - Phone:810-841-8791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI347C00000X, 347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker
No347C00000XTransportation ServicesPrivate Vehicle