Provider Demographics
NPI:1083234710
Name:ANDERSON, KELLY MANKIN (AUD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MANKIN
Last Name:ANDERSON
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 1:780 NW YORK DR STE 102
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-1054
Mailing Address - Country:US
Mailing Address - Phone:541-280-7548
Mailing Address - Fax:541-904-8378
Practice Address - Street 1:780 NW YORK DR STE 102
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-1054
Practice Address - Country:US
Practice Address - Phone:541-280-7548
Practice Address - Fax:541-904-8378
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-22
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
237600000X
OR030899231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter