Healthcare Provider Details

I. General information

NPI: 1841324860
Provider Name (Legal Business Name): KELLY A GIBSON AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 09/29/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4725 HOEN AVE
SANTA ROSA CA
95405-9402
US

IV. Provider business mailing address

750 N COMMONS DR STE 200
AURORA IL
60504-7940
US

V. Phone/Fax

Practice location:
  • Phone: 707-542-1154
  • Fax: 707-542-4818
Mailing address:
  • Phone: 630-303-5380
  • Fax: 630-303-5385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAU 2679
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code231HA2400X
TaxonomyAssistive Technology Practitioner Audiologist
License NumberAU 2679
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code231HA2500X
TaxonomyAssistive Technology Supplier Audiologist
License NumberAU 2679
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAU 2679
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: