Provider Demographics
NPI:1427225846
Name:SPAIN, KETTY M (FNP)
Entity Type:Individual
Prefix:
First Name:KETTY
Middle Name:M
Last Name:SPAIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KETTY
Other - Middle Name:M
Other - Last Name:VARGAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:514 W ATLANTIC ST
Mailing Address - Street 2:82 MAPLEWOOD LANE
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-1906
Mailing Address - Country:US
Mailing Address - Phone:434-584-2000
Mailing Address - Fax:434-447-2240
Practice Address - Street 1:514 W ATLANTIC ST
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-1906
Practice Address - Country:US
Practice Address - Phone:434-584-2000
Practice Address - Fax:434-447-2240
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167836363L00000X, 363LF0000X
NC5006092363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1427225846Medicaid
VA1427225846Medicaid
VA1427225846Medicare PIN