Provider Demographics
NPI:1699414599
Name:SPENCE, NICOLE (NP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SPENCE
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11048 E 675 N
Mailing Address - Street 2:
Mailing Address - City:OTTERBEIN
Mailing Address - State:IN
Mailing Address - Zip Code:47970-8023
Mailing Address - Country:US
Mailing Address - Phone:219-986-4379
Mailing Address - Fax:
Practice Address - Street 1:11048 E 675 N
Practice Address - Street 2:
Practice Address - City:OTTERBEIN
Practice Address - State:IN
Practice Address - Zip Code:47970-8023
Practice Address - Country:US
Practice Address - Phone:219-986-4379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-31
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71012612A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health