Provider Demographics
NPI:1376137067
Name:BROWN, KELLY (AUD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2987 DISTRICT AVE APT 524
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-1537
Mailing Address - Country:US
Mailing Address - Phone:404-401-9250
Mailing Address - Fax:
Practice Address - Street 1:14102 SULLYFIELD CIR STE 350C
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1672
Practice Address - Country:US
Practice Address - Phone:703-291-9047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-24
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAUD004261231H00000X
VA2201001909231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2201001909OtherVIRGINIA AUDIOLOGY LICENSE