Basic Information
| Provider Information | |||||||||
| NPI: | 1184057887 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THELEN | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | SPEARS | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1365B CLIFTON RD NE STE 1100 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303221013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047782020 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1365B CLIFTON RD NE STE 1100 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047782020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2013 | ||||||||
| LastUpdateDate: | 01/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT2754 | GA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 2754 | GA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.