Provider Demographics
NPI:1558518779
Name:MCKIBBEN, NICOLE RENEE (LMT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:MCKIBBEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 SE MILL ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-1908
Mailing Address - Country:US
Mailing Address - Phone:037-878-0695
Mailing Address - Fax:
Practice Address - Street 1:140 SE MILL ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1908
Practice Address - Country:US
Practice Address - Phone:037-878-0695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8227225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist