Provider Demographics
NPI:1487889465
Name:WILLIAMS, KELLY MARIE (HEARING AID DISPENSE)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:HEARING AID DISPENSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 E. BASTANCHURY ROAD
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-2782
Mailing Address - Country:US
Mailing Address - Phone:714-672-9445
Mailing Address - Fax:714-672-9448
Practice Address - Street 1:165 E. ROWLAND STREET
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3049
Practice Address - Country:US
Practice Address - Phone:626-966-6780
Practice Address - Fax:626-966-3780
Is Sole Proprietor?:No
Enumeration Date:2009-05-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA3205237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist