Provider Demographics
NPI:1528842846
Name:KELLY, MELISSA ANNE (OD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:ANNE
Last Name:KELLY
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 1:1 S WHITE HERON DR
Mailing Address - Street 2:
Mailing Address - City:LA MARQUE
Mailing Address - State:TX
Mailing Address - Zip Code:77568-6547
Mailing Address - Country:US
Mailing Address - Phone:503-729-4575
Mailing Address - Fax:
Practice Address - Street 1:2910 GULF FWY S STE F2
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-6790
Practice Address - Country:US
Practice Address - Phone:281-337-1081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10948T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist