Basic Information
| Provider Information | |||||||||
| NPI: | 1376650572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORNETTI | ||||||||
| FirstName: | WILLA | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO, MS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 855 N WESTHAVEN DR | ||||||||
| Address2: | |||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549047668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203038700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 855 N WESTHAVEN DR | ||||||||
| Address2: | |||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549047668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203038700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 49282-021 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 49282-21 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207RS0010X | 49282 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 43534400 | 05 | WI | MEDICAID |