Provider Demographics
NPI:1093915514
Name:CANNON, KELSEY ANN (OD)
Entity Type:Individual
Prefix:MRS
First Name:KELSEY
Middle Name:ANN
Last Name:CANNON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12950 CARMEL CREEK RD UNIT 103
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2130
Mailing Address - Country:US
Mailing Address - Phone:714-745-1095
Mailing Address - Fax:
Practice Address - Street 1:2100 VISTA WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-5600
Practice Address - Country:US
Practice Address - Phone:760-439-7413
Practice Address - Fax:760-439-8271
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13291152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist