Provider Demographics
NPI:1679847719
Name:KELLEY, KENDRA
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:KELLEY
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 1:400 S HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-1017
Mailing Address - Country:US
Mailing Address - Phone:817-335-2583
Mailing Address - Fax:817-546-3672
Practice Address - Street 1:211 N ANGLIN ST
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76031-4134
Practice Address - Country:US
Practice Address - Phone:817-645-5565
Practice Address - Fax:817-641-3679
Is Sole Proprietor?:No
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80310237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist