Provider Demographics
NPI:1487189429
Name:MCKIBBEN, CHANNON LAWRENCE
Entity Type:Individual
Prefix:MR
First Name:CHANNON
Middle Name:LAWRENCE
Last Name:MCKIBBEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W MAY ST
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IA
Mailing Address - Zip Code:52301-1261
Mailing Address - Country:US
Mailing Address - Phone:319-642-5543
Mailing Address - Fax:
Practice Address - Street 1:300 W MAY ST
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IA
Practice Address - Zip Code:52301-1261
Practice Address - Country:US
Practice Address - Phone:319-642-5543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA117476367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA117476OtherRN LICENSE