Provider Demographics
NPI:1801526744
Name:SPENCER, MIRANDA KAY (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:KAY
Last Name:SPENCER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1429 FLUSHING RD STE C
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-2228
Mailing Address - Country:US
Mailing Address - Phone:810-380-5060
Mailing Address - Fax:
Practice Address - Street 1:1429 FLUSHING RD STE C
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:MI
Practice Address - Zip Code:48433-2228
Practice Address - Country:US
Practice Address - Phone:810-380-5060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704327505363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health