Provider Demographics
NPI:1154884385
Name:JAMES, KELLY MARIE (OD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:JAMES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7722
Mailing Address - Country:US
Mailing Address - Phone:616-396-2316
Mailing Address - Fax:616-396-0085
Practice Address - Street 1:999 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7722
Practice Address - Country:US
Practice Address - Phone:616-396-2316
Practice Address - Fax:616-396-0085
Is Sole Proprietor?:No
Enumeration Date:2019-04-14
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4901005374152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program