Provider Demographics
NPI:1093266587
Name:CORRELL, KELLY (BCHIS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CORRELL
Suffix:
Gender:F
Credentials:BCHIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 HENDERSON DR
Mailing Address - Street 2:SUITE K
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-5840
Mailing Address - Country:US
Mailing Address - Phone:307-634-7550
Mailing Address - Fax:307-634-4463
Practice Address - Street 1:3001 HENDERSON DR
Practice Address - Street 2:SUITE K
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5840
Practice Address - Country:US
Practice Address - Phone:307-634-7550
Practice Address - Fax:307-634-4463
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE698237700000X
WY142237700000X
SD429H237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY124021800Medicaid