Healthcare Provider Details

I. General information

NPI: 1982834990
Provider Name (Legal Business Name): DIANNA L KORNHARDT ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2009
Last Update Date: 09/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 HIGHWAY 61
FESTUS MO
63028-4100
US

IV. Provider business mailing address

PO BOX 350
CRYSTAL CITY MO
63019-0350
US

V. Phone/Fax

Practice location:
  • Phone: 636-933-1299
  • Fax: 636-933-1224
Mailing address:
  • Phone: 636-933-1299
  • Fax: 636-933-1224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number118485
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number118485
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number118485
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: