Provider Demographics
NPI:1003291089
Name:TRUSSELL, KELLY CHRISTINE (OD)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:CHRISTINE
Last Name:TRUSSELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:CHRISTINE
Other - Last Name:SUMMERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1619 CATAWBA STREET
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205
Mailing Address - Country:US
Mailing Address - Phone:317-753-6443
Mailing Address - Fax:
Practice Address - Street 1:119 LIBRARY HILL LN
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-3893
Practice Address - Country:US
Practice Address - Phone:803-359-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003922A152W00000X
SC2035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist