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 1:725 S SHOOP AVE STE G-03
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-1702
Mailing Address - Country:US
Mailing Address - Phone:419-337-7832
Mailing Address - Fax:419-337-7833
Practice Address - Street 1:725 S SHOOP AVE STE G-03
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1702
Practice Address - Country:US
Practice Address - Phone:419-337-7832
Practice Address - Fax:419-337-7833
Is Sole Proprietor?:No
Enumeration Date:2011-02-23
Last Update Date:2025-06-06
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