Healthcare Provider Details

I. General information

NPI: 1376650572
Provider Name (Legal Business Name): WILLA C FORNETTI DO, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/21/2022
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 N WESTHAVEN DR
OSHKOSH WI
54904-7668
US

IV. Provider business mailing address

855 N WESTHAVEN DR
OSHKOSH WI
54904-7668
US

V. Phone/Fax

Practice location:
  • Phone: 920-303-8700
  • Fax:
Mailing address:
  • Phone: 920-303-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number49282-021
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number49282-21
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number49282
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: