Provider Demographics
NPI:1598040354
Name:NILSSON, KELLY HONSINGER (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:HONSINGER
Last Name:NILSSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:LAINE
Other - Last Name:HONSINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
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:
Practice Address - Street 1:2505 AIRPORT THRUWAY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-9114
Practice Address - Country:US
Practice Address - Phone:706-221-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALR-256-TA-B08152W00000X
MS842152W00000X
FLOPC004662152W00000X
GAOPT002997152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALR256-TA-B08OtherALABAMA LICENSE NUMBER
GA002997OtherGEORGIA LICENSE NUMBER
MS842OtherMISSISSIPPI LICENSE NUMBER
FL4662OtherFLORIDA LICENSE NUMBER