Provider Demographics
NPI:1487122099
Name:SPENCER, CANDICE (KCSA)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:SPENCER
Suffix:
Gender:F
Credentials:KCSA
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1945 SCOTTSVILLE RD B2 PMB 397
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104
Mailing Address - Country:US
Mailing Address - Phone:270-781-4828
Mailing Address - Fax:
Practice Address - Street 1:1945 SCOTTSVILLE RD B2 PMB 397
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104
Practice Address - Country:US
Practice Address - Phone:270-781-4828
Practice Address - Fax:270-781-4828
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYSA297246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant