Provider Demographics
NPI:1932616364
Name:SPICER, JENNIFER LORRAINE (APRN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LORRAINE
Last Name:SPICER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LORRAINE
Other - Last Name:IMPERATO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-9561
Mailing Address - Fax:
Practice Address - Street 1:1223 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-434-9561
Practice Address - Fax:321-434-9231
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN3385012363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105141800Medicaid
FLQG417OtherHFMG MA
FL105141800Medicaid