Provider Demographics
NPI:1396219689
Name:DUZAN, KELLY NICOLE (MLS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:DUZAN
Suffix:
Gender:F
Credentials:MLS
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:NICOLE
Other - Last Name:VIRBEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MLS
Mailing Address - Street 1:29 OPHELIA DR
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-6214
Mailing Address - Country:US
Mailing Address - Phone:501-765-6572
Mailing Address - Fax:
Practice Address - Street 1:9601 BAPTIST HEALTH DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6321
Practice Address - Country:US
Practice Address - Phone:501-202-2687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-19
Last Update Date:2019-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist