Provider Demographics
NPI:1982834990
Name:KORNHARDT, DIANNA L (ANP)
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:L
Last Name:KORNHARDT
Suffix:
Gender:F
Credentials:ANP
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 350
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63019-0350
Mailing Address - Country:US
Mailing Address - Phone:636-933-1299
Mailing Address - Fax:636-933-1224
Practice Address - Street 1:1400 HIGHWAY 61
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4100
Practice Address - Country:US
Practice Address - Phone:636-933-1299
Practice Address - Fax:636-933-1224
Is Sole Proprietor?:No
Enumeration Date:2009-07-24
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO118485163W00000X, 363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner