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General NPI Number Information
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NPI Number | 1508475211
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Entity Type | Individual
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Provider Name | KRISTEN CORNETT
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Gender | Female
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Dates
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Enumeration Date | 07/28/2020
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Last Update Date | 08/10/2022
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Provider Practice Location Address
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Address Line | 20460 ANACONDA RD
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City | FORT DRUM
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State | NY
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Zip | 13603
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Country | US
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Telephone | 719-428-9621
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Fax |
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Provider Business Mailing Address
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Address Line | 9646D BUTLER LOOP
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City | FORT DRUM
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State | NY
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Zip | 13603-3217
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT.0002144
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License Number State | CO
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