Individual
KELLIE MARIE GLADYS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
OD
Contact information
Practice address
207 HAMILTON ROAD, BLOOMINGTON, IL 61704
(309) 827-4090
Mailing address
11803 LINDEN ST, CEDAR LAKE, IN 46303-9776
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
OPT003413
GA
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
06/06/2022
Last updated
09/12/2023
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