Provider Demographics
NPI:1730355645
Name:SPENCER, COLLEEN KAY (RN, BSN)
Entity type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:KAY
Last Name:SPENCER
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 EDGEWOOD RD N
Mailing Address - Street 2:
Mailing Address - City:CUSTER
Mailing Address - State:WI
Mailing Address - Zip Code:54423-9780
Mailing Address - Country:US
Mailing Address - Phone:715-592-4092
Mailing Address - Fax:
Practice Address - Street 1:185 EDGEWOOD RD N
Practice Address - Street 2:
Practice Address - City:CUSTER
Practice Address - State:WI
Practice Address - Zip Code:54423-9780
Practice Address - Country:US
Practice Address - Phone:715-592-4092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-01
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI77124-030163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35002700Medicaid