Provider Demographics
NPI:1063085843
Name:EBBERWEIN, KATELYN MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:KATELYN
Middle Name:MARIE
Last Name:EBBERWEIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:MARIE
Other - Last Name:FLOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:140 S CHAUTAUQUA AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67211-2146
Mailing Address - Country:US
Mailing Address - Phone:620-210-1092
Mailing Address - Fax:
Practice Address - Street 1:1223 N ROCK RD BLDG C
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-1277
Practice Address - Country:US
Practice Address - Phone:316-634-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2146152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist