Provider Demographics
NPI:1134610678
Name:WHITE, KELSEY (OD)
Entity type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:
Last Name:WHITE
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 1:1102 S JAYBIRD LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701
Mailing Address - Country:US
Mailing Address - Phone:479-857-3104
Mailing Address - Fax:
Practice Address - Street 1:1517 GENE GEORGE BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-0716
Practice Address - Country:US
Practice Address - Phone:479-235-6685
Practice Address - Fax:479-231-1386
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002249152W00000X
AR2810152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist