Healthcare Provider Details

I. General information

NPI: 1194248641
Provider Name (Legal Business Name): ELLEN TALBOTT VAN NORMAN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2017
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 CONN TER STE 550
LEXINGTON KY
40508-3206
US

IV. Provider business mailing address

2920 GLENDALE MILFORD RD STE 220
CINCINNATI OH
45241-3131
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5867
  • Fax: 859-323-8510
Mailing address:
  • Phone: 513-922-9000
  • Fax: 513-922-4050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6581
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2103DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: