Healthcare Provider Details

I. General information

NPI: 1154562684
Provider Name (Legal Business Name): KELLY LYNN WATTS AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2009
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4951 ARROYO RD
LIVERMORE CA
94550-9650
US

IV. Provider business mailing address

4951 ARROYO RD
LIVERMORE CA
94550-9650
US

V. Phone/Fax

Practice location:
  • Phone: 925-449-6449
  • Fax:
Mailing address:
  • Phone: 925-449-6449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberSP-905-AU
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number519
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: