Provider Demographics
NPI:1689493025
Name:GANSER, KELLY ANN (LDO)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:GANSER
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:HOUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8064 BREWERTON RD
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039-9621
Mailing Address - Country:US
Mailing Address - Phone:315-698-0473
Mailing Address - Fax:315-698-0498
Practice Address - Street 1:8064 BREWERTON RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039-9621
Practice Address - Country:US
Practice Address - Phone:315-698-0473
Practice Address - Fax:315-698-0498
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008861156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician