Basic Information
Provider Information
NPI: 1891024261
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SPAIN
FirstName: SCARLET
MiddleName: RAE
NamePrefix: MRS.
NameSuffix:  
Credential: MSN, FNP-BC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3210 WATLING ST
Address2: MEDICAL DEPT. 8-210
City: EAST CHICAGO
State: IN
PostalCode: 463121716
CountryCode: US
TelephoneNumber: 2193993133
FaxNumber: 2193995814
Practice Location
Address1: 3210 WATLING ST
Address2: MEDICAL DEPT. 8-210
City: EAST CHICAGO
State: IN
PostalCode: 463121716
CountryCode: US
TelephoneNumber: 2193993133
FaxNumber: 2193995814
Other Information
ProviderEnumerationDate: 12/15/2009
LastUpdateDate: 10/14/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000X28160228AINY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

No ID Information.


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