Basic Information
| Provider Information | |||||||||
| NPI: | 1902853344 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | KELLE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | HAD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12927 SLEEPY WIND ST | ||||||||
| Address2: | |||||||||
| City: | MOORPARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930212935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109893092 | ||||||||
| FaxNumber: | 8055303989 | ||||||||
| Practice Location | |||||||||
| Address1: | 1767 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920215219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194406516 | ||||||||
| FaxNumber: | 6194406547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 06/30/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | HA6083 | CA | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | HA0060830 | 05 | CA | MEDICAID |