Provider Demographics
NPI:1104363936
Name:BUSACK, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:BUSACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:RIESTENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP-PC
Mailing Address - Street 1:700 CHILDRENS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2664
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 CHILDRENS DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205
Practice Address - Country:US
Practice Address - Phone:614-722-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-31
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.019360363LP2300X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0206640Medicaid