Basic Information
| Provider Information | |||||||||
| NPI: | 1306233234 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPENCER | ||||||||
| FirstName: | JADE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 MADISON AVE | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100101600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125452400 | ||||||||
| FaxNumber: | 6463120481 | ||||||||
| Practice Location | |||||||||
| Address1: | 4215 3RD AVE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104574501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182945891 | ||||||||
| FaxNumber: | 7182942468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2015 | ||||||||
| LastUpdateDate: | 06/10/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F339320 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 00695941 | 05 | NY | MEDICAID |