Provider Demographics
NPI:1174687024
Name:RICCI, KRISTIN A (RN)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:A
Last Name:RICCI
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 1:1074 COTTONWOOD LN
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-9717
Mailing Address - Country:US
Mailing Address - Phone:630-303-4519
Mailing Address - Fax:
Practice Address - Street 1:256 GALLANT FOX LN
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-9033
Practice Address - Country:US
Practice Address - Phone:585-747-0063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY579090-1163WM0705X
NYF404159-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02822668Medicaid