Provider Demographics
NPI:1245945567
Name:BANNAVONG, KHETLHAMANY ERIKA (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KHETLHAMANY
Middle Name:ERIKA
Last Name:BANNAVONG
Suffix:
Gender:
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1253 ELDER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52776-9161
Mailing Address - Country:US
Mailing Address - Phone:319-541-7785
Mailing Address - Fax:
Practice Address - Street 1:1253 ELDER RIDGE RD
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52776-9161
Practice Address - Country:US
Practice Address - Phone:195-417-7853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-20
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA114797235Z00000X
PASL018239235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist