Provider Demographics
NPI:1265554646
Name:CORNETTE, KATHRYN R (MD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:R
Last Name:CORNETTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:KATHRYN
Other - Middle Name:R
Other - Last Name:LYKES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:MOORE HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33471-0489
Mailing Address - Country:US
Mailing Address - Phone:863-946-0707
Mailing Address - Fax:863-946-3097
Practice Address - Street 1:956 HWY 27 S.W.
Practice Address - Street 2:
Practice Address - City:MOORE HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33471
Practice Address - Country:US
Practice Address - Phone:863-946-0707
Practice Address - Fax:863-946-3097
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME48971207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E49318Medicare UPIN
FL09558QMedicare ID - Type Unspecified