Provider Demographics
NPI:1225218530
Name:STENNIS, KELLIE DAWN (OD, PC)
Entity Type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:DAWN
Last Name:STENNIS
Suffix:
Gender:F
Credentials:OD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 S 27TH AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80601-2661
Mailing Address - Country:US
Mailing Address - Phone:303-654-7933
Mailing Address - Fax:303-637-9002
Practice Address - Street 1:193 S 27TH AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-2661
Practice Address - Country:US
Practice Address - Phone:303-654-7933
Practice Address - Fax:303-637-9002
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-05
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT1833152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO841381269OtherTAX ID
CO841381269OtherTAX ID
COU66123Medicare UPIN
COC41233Medicare PIN