Provider Demographics
NPI:1346724556
Name:MOONEY, KAITLIN MICHELLE (OD)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MICHELLE
Last Name:MOONEY
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 PLOVER LN
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-5766
Mailing Address - Country:US
Mailing Address - Phone:845-863-9091
Mailing Address - Fax:
Practice Address - Street 1:3200 N WICKHAM RD STE 1
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2321
Practice Address - Country:US
Practice Address - Phone:321-253-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008806152W00000X
FL6431152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist