Provider Demographics
NPI:1558199877
Name:GIANNAKOUROS, KELLEY (DO3872)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:GIANNAKOUROS
Suffix:
Gender:F
Credentials:DO3872
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1699 N WOODLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-1803
Mailing Address - Country:US
Mailing Address - Phone:386-734-6372
Mailing Address - Fax:
Practice Address - Street 1:1699 N WOODLAND BLVD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-1803
Practice Address - Country:US
Practice Address - Phone:386-734-6372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO3872156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician