Provider Demographics
NPI:1639544182
Name:KELLY, KAITLYN MARIE (AUD)
Entity Type:Individual
Prefix:DR
First Name:KAITLYN
Middle Name:MARIE
Last Name:KELLY
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 1:1100 LONG POND RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-1177
Mailing Address - Country:US
Mailing Address - Phone:585-225-1100
Mailing Address - Fax:585-225-0216
Practice Address - Street 1:1100 LONG POND RD
Practice Address - Street 2:SUITE 110
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-1177
Practice Address - Country:US
Practice Address - Phone:585-225-1100
Practice Address - Fax:585-225-0216
Is Sole Proprietor?:No
Enumeration Date:2015-12-09
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14000032759237700000X
NY002675231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1639544182OtherNPI