Provider Demographics
NPI:1093903197
Name:KELLY, KIMBERLY L (MAUD)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:L
Last Name:KELLY
Suffix:
Gender:F
Credentials:MAUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 ALICE DR STE F
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-1941
Mailing Address - Country:US
Mailing Address - Phone:803-469-7770
Mailing Address - Fax:803-469-7701
Practice Address - Street 1:1116 ALICE DR STE F
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1941
Practice Address - Country:US
Practice Address - Phone:803-469-7770
Practice Address - Fax:803-469-7701
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2083231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0179Medicaid