Provider Demographics
NPI:1609535426
Name:WENNER, KYLENE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KYLENE
Middle Name:
Last Name:WENNER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 N CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-3706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:85-180 ALA AKAU ST
Practice Address - Street 2:
Practice Address - City:WAIANAE
Practice Address - State:HI
Practice Address - Zip Code:96792-2323
Practice Address - Country:US
Practice Address - Phone:808-697-7110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30640235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist