Provider Demographics
NPI:1629371455
Name:VAN DYNE, CORAL A (LMP)
Entity Type:Individual
Prefix:
First Name:CORAL
Middle Name:A
Last Name:VAN DYNE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:CORAL
Other - Middle Name:A
Other - Last Name:GRUBBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:400 E 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1334
Mailing Address - Country:US
Mailing Address - Phone:509-838-2531
Mailing Address - Fax:
Practice Address - Street 1:505 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1426
Practice Address - Country:US
Practice Address - Phone:509-838-2531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-16
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA0025124225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist