Provider Demographics
NPI:1922139518
Name:PHELAN, KERRY ALLISON (OD)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:ALLISON
Last Name:PHELAN
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 1:1060 W PERIMETER RD
Mailing Address - Street 2:
Mailing Address - City:JB ANDREWS
Mailing Address - State:MD
Mailing Address - Zip Code:20762-6602
Mailing Address - Country:US
Mailing Address - Phone:703-681-5254
Mailing Address - Fax:
Practice Address - Street 1:238 BROOKLEY AVE SW
Practice Address - Street 2:
Practice Address - City:BOLLING AFB
Practice Address - State:DC
Practice Address - Zip Code:20032-7704
Practice Address - Country:US
Practice Address - Phone:202-404-6146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7115TG152W00000X
TX7115 TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist