Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1101X | Ophthalmic Assistant |
NPI | 1942216791 |
---|---|
Provider Name | Kelly Gant |
First Address | Florissant, MO 63031-2919 |
Second Address | Florissant, MO 63031-2919 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/08/2006 |
Last Update Date | 08/07/2007 |