Healthcare Provider Details

I. General information

NPI: 1447596564
Provider Name (Legal Business Name): KASSANDRA SUE KORNBAU DNP,PMHNP-BC,FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2012
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3768 BOARDMAN CANFIELD RD # 5
CANFIELD OH
44406-8502
US

IV. Provider business mailing address

PO BOX 1098
DALLAS NC
28034-1098
US

V. Phone/Fax

Practice location:
  • Phone: 330-798-0491
  • Fax:
Mailing address:
  • Phone: 330-798-0491
  • Fax: 330-303-4948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number14139
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: