Provider Demographics
NPI:1821127309
Name:GRAMS VANCE, KERRI LEE (OD)
Entity Type:Individual
Prefix:
First Name:KERRI
Middle Name:LEE
Last Name:GRAMS VANCE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KERRI
Other - Middle Name:LEE
Other - Last Name:VANCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:N95W18161 APPLETON AVE 103
Mailing Address - Street 2:LENS CRAFTERS
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051
Mailing Address - Country:US
Mailing Address - Phone:262-251-1378
Mailing Address - Fax:262-251-1659
Practice Address - Street 1:N95W18161 APPLETON AVE 103
Practice Address - Street 2:LENS CRAFTERS
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051
Practice Address - Country:US
Practice Address - Phone:262-251-1378
Practice Address - Fax:262-251-1659
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2546035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38598600Medicaid
WI000147270Medicare PIN
WI38598600Medicaid
WI001387780Medicare ID - Type Unspecified