Provider Demographics
NPI:1396979944
Name:VISENTINE, KELLY DUFF (OD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DUFF
Last Name:VISENTINE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3106 WOODHOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75022-8475
Mailing Address - Country:US
Mailing Address - Phone:972-259-0052
Mailing Address - Fax:
Practice Address - Street 1:3551 JUSTIN RD STE 150
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-6213
Practice Address - Country:US
Practice Address - Phone:972-355-5152
Practice Address - Fax:972-691-2958
Is Sole Proprietor?:No
Enumeration Date:2009-05-12
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4924TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist