Provider Demographics
NPI:1669600102
Name:KELLOUGH, NICKELLE ANNE (OD)
Entity type:Individual
Prefix:DR
First Name:NICKELLE
Middle Name:ANNE
Last Name:KELLOUGH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:300 S PARK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-8353
Mailing Address - Country:US
Mailing Address - Phone:954-925-2740
Mailing Address - Fax:954-923-8379
Practice Address - Street 1:300 S PARK RD STE 300
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-8353
Practice Address - Country:US
Practice Address - Phone:954-925-2740
Practice Address - Fax:954-923-8379
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-23
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3480152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist