Basic Information
Provider Information
NPI: 1003405895
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SPICER
FirstName: KRISTA
MiddleName: ELNORA
NamePrefix:  
NameSuffix:  
Credential: CPSS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 5982 RHODES RD
Address2:  
City: KENT
State: OH
PostalCode: 442408100
CountryCode: US
TelephoneNumber: 3306731347
FaxNumber: 3306783677
Practice Location
Address1: 799 S MAIN ST
Address2:  
City: LIMA
State: OH
PostalCode: 458041519
CountryCode: US
TelephoneNumber: 4192292222
FaxNumber:  
Other Information
ProviderEnumerationDate: 01/15/2021
LastUpdateDate: 01/15/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 01/15/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
175T00000X  Y    

No ID Information.


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