Provider Demographics
NPI:1992462725
Name:PALMER, KELSEY JORDAN (OD)
Entity type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:JORDAN
Last Name:PALMER
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 1:18431 N 91ST AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-0817
Mailing Address - Country:US
Mailing Address - Phone:623-393-8324
Mailing Address - Fax:
Practice Address - Street 1:18431 N 91ST AVE STE 1
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-0817
Practice Address - Country:US
Practice Address - Phone:623-393-8324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-29
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2920152W00000X
MA5539152W00000X
AZOPT-002579152W00000X
IDODP-100623152W00000X
DEI5-0000005152W00000X
NH1058152W00000X
FLTPOP102152W00000X
COOPT.0003933152W00000X
UT13429536-9934152W00000X
NY009499152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty