Healthcare Provider Details

I. General information

NPI: 1073718383
Provider Name (Legal Business Name): KRISTEN LEAH SMYLIE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9110 MENTOR AVE
MENTOR OH
44060-6404
US

IV. Provider business mailing address

9110 MENTOR AVE
MENTOR OH
44060-6404
US

V. Phone/Fax

Practice location:
  • Phone: 440-701-8030
  • Fax:
Mailing address:
  • Phone: 440-701-8030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0027290
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN331420
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: