Provider Demographics
NPI:1508647959
Name:WILSE, KELLY (LDO)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:WILSE
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4029 S PENINSULA DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-6635
Mailing Address - Country:US
Mailing Address - Phone:386-290-3022
Mailing Address - Fax:
Practice Address - Street 1:174 CYPRESS POINT PKWY
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-7438
Practice Address - Country:US
Practice Address - Phone:386-446-8510
Practice Address - Fax:386-446-8512
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6632156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician