Provider Demographics
NPI:1356032353
Name:KELLY, KYLEANA (LDO)
Entity type:Individual
Prefix:
First Name:KYLEANA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:KYLEANA
Other - Middle Name:
Other - Last Name:HURLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LDO
Mailing Address - Street 1:5671 HOLLINS RD APT 3
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-5004
Mailing Address - Country:US
Mailing Address - Phone:540-589-7942
Mailing Address - Fax:540-774-2128
Practice Address - Street 1:5350 CLEARBROOK VILLAGE LN
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-6606
Practice Address - Country:US
Practice Address - Phone:540-204-9477
Practice Address - Fax:540-774-2128
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101003349156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician