Provider Demographics
NPI:1053518118
Name:FORE, KELLY JEAN (BC-HIS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:FORE
Suffix:
Gender:F
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 S CANTON AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-4978
Mailing Address - Country:US
Mailing Address - Phone:417-864-9886
Mailing Address - Fax:
Practice Address - Street 1:802 S CANTON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-4978
Practice Address - Country:US
Practice Address - Phone:417-864-9886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001032028237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist