Provider Demographics
NPI:1770886459
Name:HIBBS, EVELYN
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:HIBBS
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:PO BOX 487
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74402-0487
Mailing Address - Country:US
Mailing Address - Phone:918-682-7879
Mailing Address - Fax:918-682-3402
Practice Address - Street 1:514 W MARTIN LUTHER KING ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-3829
Practice Address - Country:US
Practice Address - Phone:918-682-7879
Practice Address - Fax:918-682-3402
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-17
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6768171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator