Healthcare Provider Details

I. General information

NPI: 1962629741
Provider Name (Legal Business Name): KIMBERLY ANNE KELLEY AUD, CCC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9640 COMMERCE RD SUITE 106
COMMERCE TWP MI
48382-4111
US

IV. Provider business mailing address

2365 ELKRIDGE CIRCLE
HIGHLAND MI
48356
US

V. Phone/Fax

Practice location:
  • Phone: 248-360-8825
  • Fax: 248-360-8897
Mailing address:
  • Phone: 248-889-0628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number1601000165
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: