Provider Demographics
NPI:1720549231
Name:OSBORN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:OSBORN
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 1:6375 N WICKHAM RD STE 106
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-2013
Mailing Address - Country:US
Mailing Address - Phone:321-255-4884
Mailing Address - Fax:321-255-4886
Practice Address - Street 1:6375 N WICKHAM RD STE 106
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2013
Practice Address - Country:US
Practice Address - Phone:321-255-4884
Practice Address - Fax:321-255-4886
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS5425237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist