Provider Demographics
NPI:1154041747
Name:WILLHARDT, CAILEY ANNE (OD)
Entity type:Individual
Prefix:
First Name:CAILEY
Middle Name:ANNE
Last Name:WILLHARDT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CAILEY
Other - Middle Name:ANNE
Other - Last Name:PENNINGTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:833 N CASS ST
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-1613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13197 IN-23
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530
Practice Address - Country:US
Practice Address - Phone:574-247-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004361B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist