Provider Demographics
NPI:1740870245
Name:ANNEN, KELLY D (RPSGT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:ANNEN
Suffix:
Gender:F
Credentials:RPSGT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 DUBOIS DR
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3210
Mailing Address - Country:US
Mailing Address - Phone:574-372-5889
Mailing Address - Fax:
Practice Address - Street 1:2101 DUBOIS DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3210
Practice Address - Country:US
Practice Address - Phone:574-372-5889
Practice Address - Fax:574-372-5889
Is Sole Proprietor?:No
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN24478235500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist