Provider Demographics
NPI:1679135784
Name:SPAIN, NICHOLE VIRNETTA (MED)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:VIRNETTA
Last Name:SPAIN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6930 N BROAD ST APT B3
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19126-1709
Mailing Address - Country:US
Mailing Address - Phone:215-264-9154
Mailing Address - Fax:
Practice Address - Street 1:6930 N BROAD ST APT B3
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19126-1709
Practice Address - Country:US
Practice Address - Phone:215-264-9154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker