Provider Demographics
NPI:1194583609
Name:GRIDLEY, KIRA LEE-LIN (FNP)
Entity type:Individual
Prefix:
First Name:KIRA
Middle Name:LEE-LIN
Last Name:GRIDLEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5476 TOWNSEND RD
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-9754
Mailing Address - Country:US
Mailing Address - Phone:315-243-6183
Mailing Address - Fax:
Practice Address - Street 1:6870 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1031
Practice Address - Country:US
Practice Address - Phone:315-679-4367
Practice Address - Fax:315-679-4368
Is Sole Proprietor?:No
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF351912-01363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner