Provider Demographics
NPI:1164092532
Name:MIMS, KRISTINE NICHOLE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:NICHOLE
Last Name:MIMS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:NICHOLE
Other - Last Name:LAFLAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PMHNP-BC
Mailing Address - Street 1:6129 CORDERO DR
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039-7813
Mailing Address - Country:US
Mailing Address - Phone:315-276-9936
Mailing Address - Fax:
Practice Address - Street 1:6129 CORDERO DR
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039-7813
Practice Address - Country:US
Practice Address - Phone:315-276-9936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY403546363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health