MEDICARE: JOHN R CORNETT II N.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	107239	MO

General Provider Information

NPI Number	:	1225099914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN R CORNETT II N.P.

Provider Business Mailing Address
First Line	:	PO BOX 955534
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63195-5534
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1551 WALL ST
Second Line	:	4TH FLOOR
City	:	SAINT CHARLES
State	:	MO
Zip	:	63303-3539
Country	:	US
Telephone Number	:	636-669-2220
Fax Number	:	636-669-2401

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2006
Last Update Date	:	11/03/2020

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