Provider Demographics
NPI:1326657263
Name:WEDMAN, KELLY L
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:WEDMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24085 PHEASANT RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:ID
Mailing Address - Zip Code:83644-0149
Mailing Address - Country:US
Mailing Address - Phone:732-529-7120
Mailing Address - Fax:
Practice Address - Street 1:1084 N COLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8642
Practice Address - Country:US
Practice Address - Phone:208-377-0019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDHA4255237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist