Provider Demographics
NPI:1770692238
Name:KELLY, MARIE C (OD)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:C
Last Name:KELLY
Suffix:
Gender:F
Credentials:OD
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Mailing Address - Street 1:110 GLANCY STREET
Mailing Address - Street 2:SUITE 208
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072
Mailing Address - Country:US
Mailing Address - Phone:615-868-2877
Mailing Address - Fax:615-870-5771
Practice Address - Street 1:110 GLANCY ST
Practice Address - Street 2:SUITE 208
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072
Practice Address - Country:US
Practice Address - Phone:615-868-2877
Practice Address - Fax:615-870-5771
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2014-11-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TNTNOD1121152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN35967261Medicare PIN