Provider Demographics
NPI:1295470672
Name:CREWS, KELLY (OD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CREWS
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 1:3615 ROCKY STREAM DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-7173
Mailing Address - Country:US
Mailing Address - Phone:970-689-9585
Mailing Address - Fax:
Practice Address - Street 1:241 CORPORATE BLVD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4975
Practice Address - Country:US
Practice Address - Phone:970-689-9585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-01
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0618003119152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program