Provider Demographics
NPI:1669080826
Name:DJOUM, KELLY NORA (OD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:NORA
Last Name:DJOUM
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 1:7225 N CALDWELL AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-4548
Mailing Address - Country:US
Mailing Address - Phone:847-647-0707
Mailing Address - Fax:
Practice Address - Street 1:7225 N CALDWELL AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-4548
Practice Address - Country:US
Practice Address - Phone:847-647-0707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011407152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist