Provider Demographics
NPI:1710465372
Name:ISHII-KIM, KELLIE-ANNE CHIEMI (OD)
Entity Type:Individual
Prefix:
First Name:KELLIE-ANNE
Middle Name:CHIEMI
Last Name:ISHII-KIM
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 1:3621 WOODPECKER ST
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92823-1064
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:425 W BONITA AVE STE 110B
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2543
Practice Address - Country:US
Practice Address - Phone:909-394-0462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35068152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist