Provider Demographics
NPI:1104064625
Name:COONROD, VANNESS LYNN (SLP1695)
Entity type:Individual
Prefix:
First Name:VANNESS
Middle Name:LYNN
Last Name:COONROD
Suffix:
Gender:F
Credentials:SLP1695
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 N CURTIS RD
Mailing Address - Street 2:STE 204
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1338
Mailing Address - Country:US
Mailing Address - Phone:208-367-3315
Mailing Address - Fax:206-367-2674
Practice Address - Street 1:901 N CURTIS RD
Practice Address - Street 2:STE 204
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1338
Practice Address - Country:US
Practice Address - Phone:208-367-3315
Practice Address - Fax:206-367-2674
Is Sole Proprietor?:No
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1695235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist