Provider Demographics
NPI:1740630466
Name:HEREN, KELLY (OD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HEREN
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 1:3535 ROSWELL RD STE 8
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-8827
Mailing Address - Country:US
Mailing Address - Phone:678-560-8065
Mailing Address - Fax:
Practice Address - Street 1:279 N BROAD ST STE C
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-2589
Practice Address - Country:US
Practice Address - Phone:770-867-2505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 5211152W00000X
GAOPT003284152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist