Provider Demographics
NPI:1902435431
Name:KORNBLUTH, NATALIE GRAY (NP)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:GRAY
Last Name:KORNBLUTH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:662 POIRIER ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-1227
Mailing Address - Country:US
Mailing Address - Phone:805-705-9705
Mailing Address - Fax:
Practice Address - Street 1:1101 VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-6919
Practice Address - Country:US
Practice Address - Phone:415-600-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012402363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care