Provider Demographics
NPI:1194568824
Name:COFFEE, KEELEY (AUD)
Entity type:Individual
Prefix:
First Name:KEELEY
Middle Name:
Last Name:COFFEE
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:625 POLE LINE RD W STE 2B
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4270
Practice Address - Country:US
Practice Address - Phone:208-814-7350
Practice Address - Fax:208-732-8508
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-18
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAUD-6429231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist