=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043493919
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY LYNN KELLY M.A. CCC-A
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2007
-----------------------------------------------------
Last Update Date | 09/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8254 MAYFIELD RD SUITE #6
-----------------------------------------------------
City | CHESTERLAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44026-2593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-729-4325
-----------------------------------------------------
Fax | 440-729-4357
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8254 MAYFIELD RD SUITE 6
-----------------------------------------------------
City | CHESTERLAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44026-2593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-729-4325
-----------------------------------------------------
Fax | 440-729-4357
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | A. 00194
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------