Provider Demographics
NPI:1154604064
Name:BOGUE, KELLI LYNN (AUD)
Entity type:Individual
Prefix:DR
First Name:KELLI
Middle Name:LYNN
Last Name:BOGUE
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 1:2027 4TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-4572
Mailing Address - Country:US
Mailing Address - Phone:517-817-6017
Mailing Address - Fax:
Practice Address - Street 1:2027 4TH ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-4572
Practice Address - Country:US
Practice Address - Phone:517-888-5055
Practice Address - Fax:517-888-5052
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000599231H00000X, 231HA2400X, 231HA2500X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner
No231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Supplier
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter