Healthcare Provider Details

I. General information

NPI: 1750315065
Provider Name (Legal Business Name): KELLY K FRISELLA O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 ORIOLE DR
LAKE OZARK MO
65049-5608
US

IV. Provider business mailing address

149 ORIOLE DR
LAKE OZARK MO
65049-5608
US

V. Phone/Fax

Practice location:
  • Phone: 618-410-5588
  • Fax:
Mailing address:
  • Phone: 618-410-5588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2008034213
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: