Provider Demographics
NPI:1376816579
Name:SMITH, KRISTY L (RN)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:L
Last Name: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 1:6624 SOUTH ST
Mailing Address - Street 2:PO BOX 190
Mailing Address - City:RED CREEK
Mailing Address - State:NY
Mailing Address - Zip Code:13143-9510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6624 SOUTH ST
Practice Address - Street 2:
Practice Address - City:RED CREEK
Practice Address - State:NY
Practice Address - Zip Code:13143-9510
Practice Address - Country:US
Practice Address - Phone:315-754-2156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5140651163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse