Provider Demographics
NPI:1487305595
Name:KORNEGAY, WILLIE (DC)
Entity type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:
Last Name:KORNEGAY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:WILLIE
Other - Middle Name:
Other - Last Name:KORNEGAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:4916 CENTER ST STE G
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-2348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4916 CENTER ST STE G
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-2348
Practice Address - Country:US
Practice Address - Phone:253-912-9653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH61246406111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor