Provider Demographics
NPI:1982056750
Name:WILLARD, KELLY (OD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WILLARD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:19389 N 59TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6500
Mailing Address - Country:US
Mailing Address - Phone:623-537-6080
Mailing Address - Fax:623-537-6013
Practice Address - Street 1:5865 W UTOPIA RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5251
Practice Address - Country:US
Practice Address - Phone:623-806-7200
Practice Address - Fax:623-806-7210
Is Sole Proprietor?:No
Enumeration Date:2016-07-05
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2211152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist