Healthcare Provider Details

I. General information

NPI: 1104476506
Provider Name (Legal Business Name): LAUREN OLIVIA KELLY AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 01/13/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 W HARRISON ST STE 530
CHICAGO IL
60612-4861
US

IV. Provider business mailing address

2604 DEMPSTER ST STE 501
PARK RIDGE IL
60068-8429
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-5332
  • Fax:
Mailing address:
  • Phone: 847-674-5585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: