Provider Demographics
NPI:1881889251
Name:WADDELL, KELLY JACOBI (OD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:JACOBI
Last Name:WADDELL
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 1:2305 OLEANDER AVE.
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982
Mailing Address - Country:US
Mailing Address - Phone:772-465-6616
Mailing Address - Fax:772-468-2858
Practice Address - Street 1:2305 OLEANDER AVE.
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982
Practice Address - Country:US
Practice Address - Phone:772-465-6616
Practice Address - Fax:772-468-2858
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4270152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist