Provider Demographics
NPI:1235387903
Name:KENGLA, AUDREY ANN (MS,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:ANN
Last Name:KENGLA
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 834
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:AR
Mailing Address - Zip Code:72933-0834
Mailing Address - Country:US
Mailing Address - Phone:479-965-1424
Mailing Address - Fax:
Practice Address - Street 1:420 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:AR
Practice Address - Zip Code:72936-7007
Practice Address - Country:US
Practice Address - Phone:479-996-4142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2262235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159480721Medicaid