Provider Demographics
NPI:1811870942
Name:STAKELY, KENNEDY LAUREN (OD)
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:LAUREN
Last Name:STAKELY
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 1:1340 TURNER TRACE PL N
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-6869
Mailing Address - Country:US
Mailing Address - Phone:614-940-6356
Mailing Address - Fax:
Practice Address - Street 1:5406 W 38TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-2918
Practice Address - Country:US
Practice Address - Phone:317-280-8234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-28
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004613A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist