Provider Demographics
NPI:1023235835
Name:MCKIBBEN, PATRICIA LOGAN (RD, CD)
Entity type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:LOGAN
Last Name:MCKIBBEN
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 DEACONS WAY
Mailing Address - Street 2:
Mailing Address - City:WATERBURY CENTER
Mailing Address - State:VT
Mailing Address - Zip Code:05677-8111
Mailing Address - Country:US
Mailing Address - Phone:802-244-7647
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-3640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0740000157133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0740000157OtherSTATE LICENSE NUMBER