Provider Demographics
NPI:1548817695
Name:SPENCER, KESHANNA RAYANN
Entity type:Individual
Prefix:
First Name:KESHANNA
Middle Name:RAYANN
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 1:964 W LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90220-2907
Mailing Address - Country:US
Mailing Address - Phone:424-379-6704
Mailing Address - Fax:
Practice Address - Street 1:2640 INDUSTRY WAY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-4284
Practice Address - Country:US
Practice Address - Phone:310-627-4525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA269897164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse