1023444551 NPI number — KRISTAL LARE SPENCER FNP

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023444551 NPI number — KRISTAL LARE SPENCER FNP

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

SPENCER

Provider First Name:

KRISTAL

Provider Middle Name:

LARE

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

FNP

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1023444551

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

07/03/2017

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 846098

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

DALLAS

Provider Business Mailing Address State Name:

TX

Provider Business Mailing Address Postal Code:

75284-6098

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

903-324-6400

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

719 W COKE RD STE 6

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

WINNSBORO

Provider Business Practice Location Address State Name:

TX

Provider Business Practice Location Address Postal Code:

75494-3060

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

903-342-3760

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

09/16/2013

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 363LF0000X , with the licence number:  702355 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 8FD920 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: P01569955 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 352751701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 75-2616977-029 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 75-2771569-005 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 8349NQ . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 75-2616977-066 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: P01511483 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 75-2616977-121 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 75-2616977-023 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 352751702 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".