Provider Demographics
NPI:1881002392
Name:BLANCO, COBY JEANNE PATRICE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:COBY
Middle Name:JEANNE PATRICE
Last Name:BLANCO
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:JEANNE
Other - Middle Name:PATRICE
Other - Last Name:VANDENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10758 VESTONE ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89141-0480
Mailing Address - Country:US
Mailing Address - Phone:702-379-8421
Mailing Address - Fax:
Practice Address - Street 1:3121 LAS VEGAS BLVD S
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-1967
Practice Address - Country:US
Practice Address - Phone:702-770-3751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-28
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV05062692255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer