Provider Demographics
NPI:1750864914
Name:MCKIBBEN, CORALIE
Entity Type:Individual
Prefix:
First Name:CORALIE
Middle Name:
Last Name:MCKIBBEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 S TROPICAL TRL APT 619
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-4878
Mailing Address - Country:US
Mailing Address - Phone:321-313-9861
Mailing Address - Fax:
Practice Address - Street 1:225 S TROPICAL TRL APT 619
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-4878
Practice Address - Country:US
Practice Address - Phone:321-313-9861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care