Healthcare Provider Details

I. General information

NPI: 1164084521
Provider Name (Legal Business Name): KELLY MARIE CAWLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2019
Last Update Date: 07/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1689 NONCONNAH BLVD
MEMPHIS TN
38132-2105
US

IV. Provider business mailing address

1560 SE WILSHIRE PL APT 204
STUART FL
34994-5781
US

V. Phone/Fax

Practice location:
  • Phone: 901-271-4900
  • Fax:
Mailing address:
  • Phone: 772-233-5618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0003479
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: