Provider Demographics
NPI:1841466760
Name:NIEDERKORN, CONNIE LYNN (MSP, CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:LYNN
Last Name:NIEDERKORN
Suffix:
Gender:F
Credentials:MSP, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 STONEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-3664
Mailing Address - Country:US
Mailing Address - Phone:501-941-0996
Mailing Address - Fax:
Practice Address - Street 1:13 STONEWOOD CT
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-3664
Practice Address - Country:US
Practice Address - Phone:501-941-0996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR472235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist