Provider Demographics
NPI:1164811899
Name:GOLLEY-SMITH, KRISTIN LEE (RN)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:LEE
Last Name:GOLLEY-SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 HANSON RD
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:NY
Mailing Address - Zip Code:13114-4252
Mailing Address - Country:US
Mailing Address - Phone:315-997-0201
Mailing Address - Fax:
Practice Address - Street 1:201 HANSON RD
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:NY
Practice Address - Zip Code:13114-4252
Practice Address - Country:US
Practice Address - Phone:315-887-0201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-19
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY694077-1163WG0000X, 163WI0600X, 163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163WI0600XNursing Service ProvidersRegistered NurseInfection Control