MEDICARE: KRISTY L SMITH RN

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	163W00000X	Registered Nurse	5140651	NY

General Provider Information

NPI Number	:	1376816579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTY L SMITH RN

Provider Business Mailing Address
First Line	:	6624 SOUTH ST
Second Line	:	PO BOX 190
City	:	RED CREEK
State	:	NY
Zip	:	13143-9510
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6624 SOUTH ST
Second Line	:
City	:	RED CREEK
State	:	NY
Zip	:	13143-9510
Country	:	US
Telephone Number	:	315-754-2156
Fax Number	:

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

Provider Enumeration Date	:	02/17/2012
Last Update Date	:	02/17/2012

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