Provider Demographics
NPI:1114745981
Name:ROWELL, KIMBERLY LISA (LDO)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LISA
Last Name:ROWELL
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 COUNTY ROUTE 22A
Mailing Address - Street 2:
Mailing Address - City:SANDY CREEK
Mailing Address - State:NY
Mailing Address - Zip Code:13145-2179
Mailing Address - Country:US
Mailing Address - Phone:315-771-7449
Mailing Address - Fax:
Practice Address - Street 1:20823 NYS RT 3
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-5577
Practice Address - Country:US
Practice Address - Phone:315-788-1570
Practice Address - Fax:315-788-0910
Is Sole Proprietor?:No
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009054156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician