Provider Demographics
NPI:1205390887
Name:SHIELDS, KRISTY LYNN (MSED)
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:LYNN
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:
Other - Last Name:KORING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:149 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-1434
Mailing Address - Country:US
Mailing Address - Phone:585-377-2230
Mailing Address - Fax:
Practice Address - Street 1:640 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14611-3548
Practice Address - Country:US
Practice Address - Phone:585-436-0362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1656612174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1656612OtherTEACHER CERTIFICATION