Healthcare Provider Details

I. General information

NPI: 1114303625
Provider Name (Legal Business Name): KELLIE MCMAHON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 PAWTUCKET AVE
EAST PROVIDENCE RI
02914-1718
US

IV. Provider business mailing address

1970 PAWTUCKET AVE
EAST PROVIDENCE RI
02914-1718
US

V. Phone/Fax

Practice location:
  • Phone: 401-438-1166
  • Fax: 401-438-1614
Mailing address:
  • Phone: 401-438-1166
  • Fax: 401-438-1614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5116
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: