Provider Demographics
NPI:1366160277
Name:KORNEGAY, WILLIAM LANE (APRN)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:LANE
Last Name:KORNEGAY
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:54 RONALD RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3819
Mailing Address - Country:US
Mailing Address - Phone:860-235-6983
Mailing Address - Fax:
Practice Address - Street 1:21 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4906
Practice Address - Country:US
Practice Address - Phone:860-439-6400
Practice Address - Fax:860-390-1463
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-16
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2022030521363LP0808X
CT116351163W00000X
CT11161163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health