Provider Demographics
NPI:1306296231
Name:OWENS, KELLY L (OD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:L
Last Name:OWENS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:NEAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1350 E MAIN ST STE 20
Mailing Address - Street 2:
Mailing Address - City:CLARION
Mailing Address - State:PA
Mailing Address - Zip Code:16214-6278
Mailing Address - Country:US
Mailing Address - Phone:814-226-4862
Mailing Address - Fax:814-226-8741
Practice Address - Street 1:1350 E MAIN ST STE 20
Practice Address - Street 2:
Practice Address - City:CLARION
Practice Address - State:PA
Practice Address - Zip Code:16214-6278
Practice Address - Country:US
Practice Address - Phone:814-226-4862
Practice Address - Fax:814-226-8741
Is Sole Proprietor?:No
Enumeration Date:2016-06-22
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003160152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA6007380001OtherMEDICARE PTAN
PA110945Medicare PIN