Provider Demographics
NPI:1538256375
Name:CHURCHILL, KELLY M (AUD, CCC-A)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:M
Last Name:CHURCHILL
Suffix:
Gender:F
Credentials:AUD, CCC-A
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:FROST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD, CCC-A
Mailing Address - Street 1:4351 E LOHMAN AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8258
Mailing Address - Country:US
Mailing Address - Phone:575-521-9795
Mailing Address - Fax:
Practice Address - Street 1:4351 E LOHMAN AVE STE 103
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8258
Practice Address - Country:US
Practice Address - Phone:575-521-9795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1807231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK2358Medicaid