Provider Demographics
NPI:1730520651
Name:PACK, KELLY R (AUD)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:R
Last Name:PACK
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 1:2011 MALL DR STE 4
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-2550
Mailing Address - Country:US
Mailing Address - Phone:903-792-3986
Mailing Address - Fax:903-792-3935
Practice Address - Street 1:2011 MALL DR STE 4
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2550
Practice Address - Country:US
Practice Address - Phone:903-792-3986
Practice Address - Fax:903-792-3935
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80696237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter