Provider Demographics
NPI:1942407069
Name:VETAL, KIMBERLY L (FNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:VETAL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 E OLD STURBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRIMFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01010-9647
Mailing Address - Country:US
Mailing Address - Phone:413-245-0966
Mailing Address - Fax:413-245-4553
Practice Address - Street 1:255 E OLD STURBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRIMFIELD
Practice Address - State:MA
Practice Address - Zip Code:01010-9647
Practice Address - Country:US
Practice Address - Phone:413-245-3389
Practice Address - Fax:413-245-4553
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA195415363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0379191Medicaid
MDNP3934OtherBCBS
MAVENP3934Medicare ID - Type Unspecified
MA0379191Medicaid
MANP393401Medicare PIN