Provider Demographics
NPI:1255521902
Name:DRAKE, KELLY JEAN (OD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:DRAKE
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 1:1299 SILERY RD
Mailing Address - Street 2:
Mailing Address - City:INDIAN RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:49749-9513
Mailing Address - Country:US
Mailing Address - Phone:989-513-1968
Mailing Address - Fax:
Practice Address - Street 1:110 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-1741
Practice Address - Country:US
Practice Address - Phone:989-348-2833
Practice Address - Fax:989-843-2834
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004442152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist