Provider Demographics
NPI:1730522475
Name:SPAKE, COLIN (FNP)
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:
Last Name:SPAKE
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 RHONDA WAY
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-3481
Mailing Address - Country:US
Mailing Address - Phone:415-419-4111
Mailing Address - Fax:
Practice Address - Street 1:630 DRAKE AVE
Practice Address - Street 2:
Practice Address - City:SAUSALITO
Practice Address - State:CA
Practice Address - Zip Code:94965-1107
Practice Address - Country:US
Practice Address - Phone:415-339-8813
Practice Address - Fax:415-339-8814
Is Sole Proprietor?:No
Enumeration Date:2013-04-11
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA789899163W00000X
CA22806363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse