MEDICARE: KELLI AMMON BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	11109001-2506	UT
2	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1528417680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI AMMON BCBA

Provider Business Mailing Address
First Line	:	10175 FORTUNE PKWY UNIT 903
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-6755
Country	:	US
Telephone Number	:	904-538-0713
Fax Number	:	904-538-0714

Provider Business Practice Location Address
First Line	:	6196 LAKE GRAY BLVD STE 117
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32244-5867
Country	:	US
Telephone Number	:	855-300-6408
Fax Number	:	904-578-5103

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2016
Last Update Date	:	11/13/2024

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Directions to “ KELLI AMMON BCBA” Practice Location

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