Provider Demographics
NPI:1619595352
Name:BRALEY, ELLEN KAY (OD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:KAY
Last Name:BRALEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:K
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-1304
Mailing Address - Country:US
Mailing Address - Phone:217-854-7611
Mailing Address - Fax:217-854-8120
Practice Address - Street 1:300 N BROAD ST
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-1304
Practice Address - Country:US
Practice Address - Phone:217-854-7611
Practice Address - Fax:217-854-8120
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011451152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist