Provider Demographics
NPI:1578815742
Name:KELLY H NILSSON, OD, PA
Entity Type:Organization
Organization Name:KELLY H NILSSON, OD, PA
Other - Org Name:NILSSON EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:HONSINGER
Authorized Official - Last Name:NILSSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:601-347-1725
Mailing Address - Street 1:320 STEELE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31820-4647
Mailing Address - Country:US
Mailing Address - Phone:601-347-1725
Mailing Address - Fax:706-682-3931
Practice Address - Street 1:3580 MASSEE LN STE G
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-2586
Practice Address - Country:US
Practice Address - Phone:762-583-6110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-11
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
FL4662152W00000X
GAOPT002997152W00000X
MS842152W00000X
AL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A10819OtherEYEMED
A10819OtherHUMANA VCP
A10819OtherHUMANA VCP