Provider Demographics
NPI:1841291549
Name:KELLY, JULIE L (AUD)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:L
Last Name:KELLY
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 1:1930 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-1406
Mailing Address - Country:US
Mailing Address - Phone:707-443-4503
Mailing Address - Fax:707-443-7672
Practice Address - Street 1:1930 MYRTLE AVE STE A
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-1406
Practice Address - Country:US
Practice Address - Phone:707-443-4503
Practice Address - Fax:707-443-7672
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2018-03-07
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
CAHA5064237600000X
CAAU2309231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU0023090Medicaid
CAZZZ30087ZMedicare ID - Type Unspecified