Basic Information
Provider Information | |||||||||
NPI: | 1801902689 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOMP | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | N.P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1001 LAKESIDE AVE E | ||||||||
Address2: | #1200 | ||||||||
City: | CLEVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 441141158 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10 SEVERANCE CIR | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND HEIGHTS | ||||||||
State: | OH | ||||||||
PostalCode: | 441181533 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2165247377 | ||||||||
FaxNumber: | 2162972532 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/22/2006 | ||||||||
LastUpdateDate: | 10/08/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN-179016 | OH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363L00000X | NP-02236 | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 2283809 | 05 | OH |   | MEDICAID |