1144605767 NPI number — JOHANNA SPENCER

Table of content: JOHANNA SPENCER (NPI 1144605767)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144605767 NPI number — JOHANNA SPENCER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPENCER
Provider First Name:
JOHANNA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SITZ
Provider Other First Name:
JOHANNA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN-NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1144605767
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2707 L ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORD
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68862-1275
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-728-4202
Provider Business Mailing Address Fax Number:
308-728-3500

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2707 L ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORD
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68862-1275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-728-4202
Provider Business Practice Location Address Fax Number:
308-728-3500
Provider Enumeration Date:
07/24/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  111832 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 111832 . This is a "STATE MEDICAL LICENSE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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