Provider Demographics
NPI:1417254764
Name:KHANDAKER, KATHRYN ANN (MSN, RN, CNP)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:ANN
Last Name:KHANDAKER
Suffix:
Gender:F
Credentials:MSN, RN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 GLENDALE AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-2426
Mailing Address - Country:US
Mailing Address - Phone:419-383-3588
Mailing Address - Fax:419-383-3238
Practice Address - Street 1:3000 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2595
Practice Address - Country:US
Practice Address - Phone:419-383-3588
Practice Address - Fax:419-383-3238
Is Sole Proprietor?:No
Enumeration Date:2011-02-23
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.12210-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3139160Medicaid