Provider Demographics
NPI:1689130940
Name:LUNSFORD, KELLY NICOLE (MED CF SLP)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:NICOLE
Last Name:LUNSFORD
Suffix:
Gender:F
Credentials:MED CF SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 MEMORIAL DR APT 2704
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37415-5535
Mailing Address - Country:US
Mailing Address - Phone:770-653-1707
Mailing Address - Fax:
Practice Address - Street 1:2403 BATTLEFIELD PKWY
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-4033
Practice Address - Country:US
Practice Address - Phone:706-866-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1373774235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist