Healthcare Provider Details

I. General information

NPI: 1063053221
Provider Name (Legal Business Name): SHAYNA SMITH ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHAYNA WILL

II. Dates (important events)

Enumeration Date: 09/30/2019
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

189 CEMETERY RD
FLY CREEK NY
13337-2103
US

IV. Provider business mailing address

189 CEMETERY RD
FLY CREEK NY
13337-2103
US

V. Phone/Fax

Practice location:
  • Phone: 607-953-9759
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number004239
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: