Basic Information
| Provider Information | |||||||||
| NPI: | 1003227059 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREESE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | NOEL | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 N MCKEMY AVE | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852262654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808354472 | ||||||||
| FaxNumber: | 4808938172 | ||||||||
| Practice Location | |||||||||
| Address1: | 2380 TROOP DR | ||||||||
| Address2: | SUITE201 | ||||||||
| City: | SARTELL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563774636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202583915 | ||||||||
| FaxNumber: | 3202583917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2014 | ||||||||
| LastUpdateDate: | 01/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT-0022511 | AZ | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.