Provider Demographics
NPI:1851622070
Name:MCKIBBEN, MELISSA A (NP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:MCKIBBEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:PRIMIANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2210 SUGAR HILL RD
Mailing Address - Street 2:
Mailing Address - City:EAST WALLINGFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05742-9602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 STRATTON RD
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4621
Practice Address - Country:US
Practice Address - Phone:802-773-3386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-28
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101.0135178363L00000X
COC-APN.0004534-C-NP363L00000X
MECNP221310363LA2100X
NH079526-23363LF0000X
CO173208163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO020804OtherKAISER COMMERCIAL NUMBER
CO32037775Medicaid
VT6709728Medicaid
NH3133777Medicaid