Provider Demographics
NPI:1942216791
Name:GANT, KELLY (COT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GANT
Suffix:
Gender:F
Credentials:COT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N US HIGHWAY 67
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-2919
Mailing Address - Country:US
Mailing Address - Phone:314-838-0321
Mailing Address - Fax:
Practice Address - Street 1:900 N US HIGHWAY 67
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-2919
Practice Address - Country:US
Practice Address - Phone:314-838-0321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1101XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic Assistant