Provider Demographics
NPI:1588466791
Name:SPENCER, MICHAELA
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:SPENCER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 DIVISION AVE
Mailing Address - Street 2:
Mailing Address - City:ELLWOOD CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16117-2810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:425 DIVISION AVE
Practice Address - Street 2:
Practice Address - City:ELLWOOD CITY
Practice Address - State:PA
Practice Address - Zip Code:16117-2810
Practice Address - Country:US
Practice Address - Phone:724-714-4476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-26
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN007220133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered