Provider Demographics
NPI:1578081725
Name:SMITH, KRISTA NICHOLE
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:NICHOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 214
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:OH
Mailing Address - Zip Code:44822-0214
Mailing Address - Country:US
Mailing Address - Phone:419-566-5974
Mailing Address - Fax:
Practice Address - Street 1:1451 LUCAS RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-8682
Practice Address - Country:US
Practice Address - Phone:419-589-5511
Practice Address - Fax:419-589-5054
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN391975163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty