Provider Demographics
NPI:1538638788
Name:LUNDBERG, KELLY RIPPY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RIPPY
Last Name:LUNDBERG
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 1:304 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:WA
Mailing Address - Zip Code:99171-8772
Mailing Address - Country:US
Mailing Address - Phone:509-648-3313
Mailing Address - Fax:
Practice Address - Street 1:304 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:WA
Practice Address - Zip Code:99171-8772
Practice Address - Country:US
Practice Address - Phone:509-648-3314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00003551235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist