Provider Demographics
NPI:1144687658
Name:EATON, KELLY A (AUD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:EATON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:DOLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:11945 SAN JOSE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1627
Mailing Address - Country:US
Mailing Address - Phone:516-521-9462
Mailing Address - Fax:904-396-4893
Practice Address - Street 1:10475 CENTURION PKWY N STE 300
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-5004
Practice Address - Country:US
Practice Address - Phone:904-399-0350
Practice Address - Fax:904-399-5914
Is Sole Proprietor?:No
Enumeration Date:2016-01-28
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY57002583231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist