Provider Demographics
NPI:1184775587
Name:LEWIS, KELLI SUZANNE (ABOC)
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:SUZANNE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-2902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:304-522-8313
Practice Address - Street 1:1508 6TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-2902
Practice Address - Country:US
Practice Address - Phone:304-522-6256
Practice Address - Fax:304-522-8313
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS. 7050156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician