Provider Demographics
NPI:1629242797
Name:CORNETT, WILLY CLARKSON (RN)
Entity Type:Individual
Prefix:MR
First Name:WILLY
Middle Name:CLARKSON
Last Name:CORNETT
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:550 POPE AVENUE
Mailing Address - Street 2:MUNSON ARMY HEALTH CENTER
Mailing Address - City:FORT LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66027
Mailing Address - Country:US
Mailing Address - Phone:913-684-6562
Mailing Address - Fax:913-684-6208
Practice Address - Street 1:550 POPE AVENUE
Practice Address - Street 2:MUNSON ARMY HEALTH CENTER
Practice Address - City:FORT LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66027
Practice Address - Country:US
Practice Address - Phone:913-684-6562
Practice Address - Fax:913-684-6208
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN2915302163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse