Provider Demographics
NPI:1174521256
Name:SPENCER, SIMONE M (CNM)
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:M
Last Name:SPENCER
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 SINCLAIR LN
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21213-2029
Mailing Address - Country:US
Mailing Address - Phone:410-732-8800
Mailing Address - Fax:443-703-3242
Practice Address - Street 1:1245 EASTERN BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21221-3422
Practice Address - Country:US
Practice Address - Phone:410-558-4700
Practice Address - Fax:410-780-0364
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF001074-1176B00000X
MDR224419363L00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02532281Medicaid
NY02532281Medicaid
NYMGM171Medicare ID - Type Unspecified