Healthcare Provider Details

I. General information

NPI: 1770553463
Provider Name (Legal Business Name): ANITA F CORNETT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 03/07/2023
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 MARIE LANGDON DR
MANCHESTER KY
40962-6388
US

IV. Provider business mailing address

509 MEMORIAL DR STE 2
MANCHESTER KY
40962-6196
US

V. Phone/Fax

Practice location:
  • Phone: 606-598-5104
  • Fax: 606-598-0983
Mailing address:
  • Phone: 606-598-5104
  • Fax: 606-598-0983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number27472
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number27472
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: