Provider Demographics
NPI:1366757932
Name:NGUYEN, KELLY T
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:T
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2514
Mailing Address - Country:US
Mailing Address - Phone:203-465-1415
Mailing Address - Fax:203-465-1481
Practice Address - Street 1:336 MAIN ST
Practice Address - Street 2:
Practice Address - City:ANSONIA
Practice Address - State:CT
Practice Address - Zip Code:06401-2303
Practice Address - Country:US
Practice Address - Phone:203-732-3937
Practice Address - Fax:203-465-1481
Is Sole Proprietor?:No
Enumeration Date:2010-08-08
Last Update Date:2021-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007550152W00000X
CT002872152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist