Provider Demographics
NPI:1528332426
Name:WILLAERT, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:WILLAERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 455 BOX 208
Mailing Address - Street 2:FPO, AP 96540-0003
Mailing Address - City:AGANA HEIGHTS
Mailing Address - State:GU
Mailing Address - Zip Code:96910
Mailing Address - Country:US
Mailing Address - Phone:671-344-7265
Mailing Address - Fax:
Practice Address - Street 1:620 JOHN PAUL JONES CIRCLE
Practice Address - Street 2:NAVAL MEDICAL CENTER PORTSMOUTH
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708
Practice Address - Country:US
Practice Address - Phone:757-953-2518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-24
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01022035832083X0100X, 171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Single Specialty
No171000000XOther Service ProvidersMilitary Health Care ProviderGroup - Single Specialty