Provider Demographics
NPI:1295240695
Name:SPENCER, MISTY
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:SPENCER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2369 SCHELLSBURG RD
Mailing Address - Street 2:ENTRANCE #12
Mailing Address - City:QUEEN
Mailing Address - State:PA
Mailing Address - Zip Code:16670-8935
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10455 LINCOLN HWY
Practice Address - Street 2:ENTRANCE #12
Practice Address - City:EVERETT
Practice Address - State:PA
Practice Address - Zip Code:15537-7046
Practice Address - Country:US
Practice Address - Phone:814-623-3570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-06
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR241759363L00000X
PASP018173363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily