Provider Demographics
NPI:1275083388
Name:PAYNE, KELLI (OD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:PAYNE
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 1:5405 PEARL DR STE 4
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47712-8102
Mailing Address - Country:US
Mailing Address - Phone:812-426-2066
Mailing Address - Fax:812-426-1086
Practice Address - Street 1:5405 PEARL DR
Practice Address - Street 2:#4
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47712
Practice Address - Country:US
Practice Address - Phone:812-426-2066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-12
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004000B152W00000X
IN18004000A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist