Provider Demographics
NPI:1710473780
Name:HERRON, KELLY (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:HERRON
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 1:726 FULTON ST APT 432
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37402-6933
Mailing Address - Country:US
Mailing Address - Phone:860-803-3355
Mailing Address - Fax:
Practice Address - Street 1:7405 SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-2661
Practice Address - Country:US
Practice Address - Phone:423-855-8522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist