Provider Demographics
NPI:1861109191
Name:SPAIN THOMAS, VIRGINIA (RDN, LD,CLC)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:SPAIN THOMAS
Suffix:
Gender:F
Credentials:RDN, LD,CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3542 WATER FRONT DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-5005
Mailing Address - Country:US
Mailing Address - Phone:404-428-0795
Mailing Address - Fax:
Practice Address - Street 1:3542 WATER FRONT DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30506-5005
Practice Address - Country:US
Practice Address - Phone:404-428-0795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD005231133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered