Provider Demographics
NPI:1790443463
Name:SMILEY, KAITLIN MARIE (NP)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MARIE
Last Name:SMILEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 WILLOW POND WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:PENFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14526-2638
Mailing Address - Country:US
Mailing Address - Phone:585-377-5420
Mailing Address - Fax:
Practice Address - Street 1:43 WILLOW POND WAY STE 200
Practice Address - Street 2:
Practice Address - City:PENFIELD
Practice Address - State:NY
Practice Address - Zip Code:14526-2638
Practice Address - Country:US
Practice Address - Phone:585-377-5420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF348509-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily