Basic Information
| Provider Information | |||||||||
| NPI: | 1316972029 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPENCER | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | R.N.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2450 N PARK DR STE A | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472032292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123486373 | ||||||||
| FaxNumber: | 8123486373 | ||||||||
| Practice Location | |||||||||
| Address1: | 2450 N PARK DR STE A | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472032292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123486373 | ||||||||
| FaxNumber: | 8123486373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 71001111A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 200885470 | 05 | IN | MEDICAID | 000000548384 | 01 | IN | ANTHEM | OTHER |