Provider Demographics
NPI:1508213398
Name:KIBOT, EDWAN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:EDWAN
Middle Name:
Last Name:KIBOT
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1871 IVYSTONE CT
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23238-4213
Mailing Address - Country:US
Mailing Address - Phone:218-207-8373
Mailing Address - Fax:
Practice Address - Street 1:1871 IVYSTONE CT
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23238-4213
Practice Address - Country:US
Practice Address - Phone:218-207-8373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173580363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily