Provider Demographics
NPI:1336391317
Name:SMITH, KATHRYN ELAINE
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ELAINE
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 1:1607 BEAVER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WEST EDMESTON
Mailing Address - State:NY
Mailing Address - Zip Code:13485-2707
Mailing Address - Country:US
Mailing Address - Phone:315-899-6227
Mailing Address - Fax:
Practice Address - Street 1:1607 BEAVER CREEK RD
Practice Address - Street 2:
Practice Address - City:WEST EDMESTON
Practice Address - State:NY
Practice Address - Zip Code:13485-2707
Practice Address - Country:US
Practice Address - Phone:315-899-6227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261814-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse