Provider Demographics
NPI:1548302649
Name:STATON, KELLY (OD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:STATON
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 1:124 JAGLE ST
Mailing Address - Street 2:
Mailing Address - City:COTATI
Mailing Address - State:CA
Mailing Address - Zip Code:94931-5375
Mailing Address - Country:US
Mailing Address - Phone:707-792-6783
Mailing Address - Fax:
Practice Address - Street 1:320 PETALUMA BLVD S
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-4245
Practice Address - Country:US
Practice Address - Phone:707-762-8643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10012T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist