Provider Demographics
NPI:1932189354
Name:SOULTS, KELLY JOY (OD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JOY
Last Name:SOULTS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JOY
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1250 NW 128TH ST STE 150
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-7433
Mailing Address - Country:US
Mailing Address - Phone:515-223-9595
Mailing Address - Fax:515-223-9795
Practice Address - Street 1:1250 NW 128TH ST STE 150
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-7433
Practice Address - Country:US
Practice Address - Phone:515-223-9595
Practice Address - Fax:515-223-9795
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAIA02283152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAV04084Medicare UPIN
IAI14744Medicare ID - Type Unspecified