Provider Demographics
NPI:1689046260
Name:HIBBS, KELLY ROCHELLE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ROCHELLE
Last Name:HIBBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ROCHELLE
Other - Last Name:EARLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4171 WESTPORT RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-2739
Mailing Address - Country:US
Mailing Address - Phone:502-896-8868
Mailing Address - Fax:028-956-2785
Practice Address - Street 1:4171 WESTPORT RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-2739
Practice Address - Country:US
Practice Address - Phone:502-896-8868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-22
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009820363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201335080Medicaid
KY7100372730Medicaid
IN201335080Medicaid