MEDICARE: KIRA LEE-LIN GRIDLEY FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	F351912-01	NY

General Provider Information

NPI Number	:	1194583609
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIRA LEE-LIN GRIDLEY FNP-C

Provider Business Mailing Address
First Line	:	109 GENESEE ST
Second Line	:
City	:	ONEIDA
State	:	NY
Zip	:	13421-2703
Country	:	US
Telephone Number	:	315-231-5530
Fax Number	:

Provider Business Practice Location Address
First Line	:	6870 E GENESEE ST
Second Line	:
City	:	FAYETTEVILLE
State	:	NY
Zip	:	13066-1031
Country	:	US
Telephone Number	:	315-679-4367
Fax Number	:	315-679-4368

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2024
Last Update Date	:	04/07/2026

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