Healthcare Provider Details

I. General information

NPI: 1881693547
Provider Name (Legal Business Name): KELLY LYNNE CUNNINGHAM OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 10/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 E WASHINGTON ST
MARTINSVILLE IN
46151-1554
US

IV. Provider business mailing address

219 E WASHINGTON ST
MARTINSVILLE IN
46151-1554
US

V. Phone/Fax

Practice location:
  • Phone: 765-342-6654
  • Fax: 765-342-0418
Mailing address:
  • Phone: 765-342-6654
  • Fax: 765-342-0418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003161B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: