Provider Demographics
NPI:1447599030
Name:WILLETTE, KENT ALAN (IDMT, NREMT-P)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:ALAN
Last Name:WILLETTE
Suffix:
Gender:M
Credentials:IDMT, NREMT-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 PARKWAY PL
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-5341
Mailing Address - Country:US
Mailing Address - Phone:931-454-3537
Mailing Address - Fax:
Practice Address - Street 1:101 PARKWAY PL
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-5341
Practice Address - Country:US
Practice Address - Phone:931-454-3537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-03
Last Update Date:2013-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1103XAmbulatory Health Care FacilitiesClinic/CenterMilitary Ambulatory Procedure Visits Operational (Transportable)