Provider Demographics
NPI:1871248229
Name:HUMBURG, KASANDRA (RN)
Entity Type:Individual
Prefix:
First Name:KASANDRA
Middle Name:
Last Name:HUMBURG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KASANDRA
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 293
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:IA
Mailing Address - Zip Code:50482-0293
Mailing Address - Country:US
Mailing Address - Phone:641-512-5285
Mailing Address - Fax:
Practice Address - Street 1:320 N EISENHOWER AVE
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-1521
Practice Address - Country:US
Practice Address - Phone:641-424-2391
Practice Address - Fax:641-424-0783
Is Sole Proprietor?:No
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA140250163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA140250OtherREGISTERED NURSE LICENSE