Provider Demographics
NPI:1649523804
Name:MCKIBBEN, J SUZANNE (RN, CWON)
Entity type:Individual
Prefix:MS
First Name:J
Middle Name:SUZANNE
Last Name:MCKIBBEN
Suffix:
Gender:F
Credentials:RN, CWON
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6732 67TH WAY N
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33781-5049
Mailing Address - Country:US
Mailing Address - Phone:727-248-9219
Mailing Address - Fax:
Practice Address - Street 1:6732 67TH WAY N
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-5049
Practice Address - Country:US
Practice Address - Phone:727-248-9219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-24
Last Update Date:2018-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9277872163WW0000X
FL9277872163WX1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WX1500XNursing Service ProvidersRegistered NurseOstomy CareGroup - Single Specialty
No163WW0000XNursing Service ProvidersRegistered NurseWound Care