Provider Demographics
NPI:1740485903
Name:KORNBLUTH, PENELOPE GRACE (RN, NP, MSN)
Entity type:Individual
Prefix:
First Name:PENELOPE
Middle Name:GRACE
Last Name:KORNBLUTH
Suffix:
Gender:F
Credentials:RN, NP, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8631 W 3RD ST
Mailing Address - Street 2:SUITE 800E
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5901
Mailing Address - Country:US
Mailing Address - Phone:310-423-0840
Mailing Address - Fax:
Practice Address - Street 1:8631 W 3RD ST
Practice Address - Street 2:SUITE 800E
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5901
Practice Address - Country:US
Practice Address - Phone:310-423-0840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16805363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health