Provider Demographics
NPI:1215588033
Name:HIBBS, JOHNATHAN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:
Last Name:HIBBS
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5470 KINGS ISLAND DRIVE
Mailing Address - Street 2:STE 120
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040
Mailing Address - Country:US
Mailing Address - Phone:513-791-4490
Mailing Address - Fax:513-791-7287
Practice Address - Street 1:5470 KINGS ISLAND DRIVE
Practice Address - Street 2:STE 120
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040
Practice Address - Country:US
Practice Address - Phone:513-791-4490
Practice Address - Fax:513-791-7287
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH405604363L00000X
OHCNP.025755363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner