Provider Demographics
NPI:1902853344
Name:DAVIS, KELLE L (HAD)
Entity Type:Individual
Prefix:MS
First Name:KELLE
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:HAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12927 SLEEPY WIND ST
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-2935
Mailing Address - Country:US
Mailing Address - Phone:310-989-3092
Mailing Address - Fax:805-530-3989
Practice Address - Street 1:1767 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-5219
Practice Address - Country:US
Practice Address - Phone:619-440-6516
Practice Address - Fax:619-440-6547
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA6083237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHA0060830Medicaid