Provider Demographics
NPI:1609807833
Name:WAUGAMAN, KELLY DIANE (AUD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:DIANE
Last Name:WAUGAMAN
Suffix:
Gender:
Credentials:AUD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:HEYMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5 CALIENTE RD # 5
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-9100
Mailing Address - Country:US
Mailing Address - Phone:505-466-7526
Mailing Address - Fax:
Practice Address - Street 1:5 CALIENTE RD STE 5A
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87508-9102
Practice Address - Country:US
Practice Address - Phone:505-466-7526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3966237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM34M716604Medicare PIN