Provider Demographics
NPI:1336111806
Name:KOMOSA, KRISTINE A (CNP)
Entity Type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:A
Last Name:KOMOSA
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 E RIVER ST
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-5902
Mailing Address - Country:US
Mailing Address - Phone:440-329-7500
Mailing Address - Fax:440-414-9059
Practice Address - Street 1:3600 KOLBE RD
Practice Address - Street 2:SUITE 127
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-1654
Practice Address - Country:US
Practice Address - Phone:440-414-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-06796363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2599791Medicaid
OH2599791Medicaid