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General NPI Number Information
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NPI Number | 1780953364
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Entity Type | Individual
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Provider Name | KELLY CONYER HAGOOD O.D.
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Gender | Female
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Dates
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Enumeration Date | 12/27/2011
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Last Update Date | 10/08/2024
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Provider Practice Location Address
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Address Line | 2306 KNOB CREEK RD STE 106
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City | JOHNSON CITY
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State | TN
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Zip | 37604-2366
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Country | US
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Telephone | 423-929-2020
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Fax | 423-929-3140
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Provider Business Mailing Address
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Address Line | 2011 N ROAN ST DR. CARLSON & ASSOCIATES IN THE MALL AT JOHNSON CITY
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City | JOHNSON CITY
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State | TN
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Zip | 37601-3130
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Country | US
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Telephone | 423-610-7155
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OD0000002994
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License Number State | TN
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