Provider Demographics
NPI:1447596564
Name:KORNBAU, KASSANDRA SUE (DNP,PMHNP-BC,FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KASSANDRA
Middle Name:SUE
Last Name:KORNBAU
Suffix:
Gender:F
Credentials:DNP,PMHNP-BC,FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:NC
Mailing Address - Zip Code:28034-1098
Mailing Address - Country:US
Mailing Address - Phone:330-798-0491
Mailing Address - Fax:330-303-4948
Practice Address - Street 1:3768 BOARDMAN CANFIELD RD # 5
Practice Address - Street 2:
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-8502
Practice Address - Country:US
Practice Address - Phone:330-798-0491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-18
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH14139363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0082856Medicaid
OHH206462OtherMEDICARE PTAN