Provider Demographics
NPI:1942224647
Name:DAVENPORT, KELLI L (AUD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:L
Last Name:DAVENPORT
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 1:2740 E SEEGER CT
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93292-1373
Mailing Address - Country:US
Mailing Address - Phone:559-827-5870
Mailing Address - Fax:
Practice Address - Street 1:206 N SANTA FE ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93292-6436
Practice Address - Country:US
Practice Address - Phone:559-791-1779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU2649237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8338337Medicaid
WA134946OtherLABOR & INDUSTRY
CACD318ZMedicare UPIN
WA8338337Medicaid