Provider Demographics
NPI:1609508738
Name:KELLY, ELLEN BROOKE (OD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:BROOKE
Last Name:KELLY
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 1:2191 LUMBERJACK DR
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:KY
Mailing Address - Zip Code:41048-7929
Mailing Address - Country:US
Mailing Address - Phone:606-260-0639
Mailing Address - Fax:
Practice Address - Street 1:7727 MALL RD STE B
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-2666
Practice Address - Country:US
Practice Address - Phone:859-282-1751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2280DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist