Provider Demographics
NPI:1770137598
Name:KORNHAUSER, AMY (FNP-BC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:KORNHAUSER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 HARTFORD ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904
Mailing Address - Country:US
Mailing Address - Phone:765-742-1567
Mailing Address - Fax:765-742-2750
Practice Address - Street 1:2121 S GOPHER DR BLDG
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IN
Practice Address - Zip Code:46041-6800
Practice Address - Country:US
Practice Address - Phone:765-650-7875
Practice Address - Fax:765-650-7803
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-30
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71009234A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300030438Medicaid