Basic Information
| Provider Information | |||||||||
| NPI: | 1184923559 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIBBE | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | SUSAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | AUDIOLOGIST | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KIBBE-MICHAL | ||||||||
| OtherFirstName: | KAREN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8800 SE SUNNYSIDE RD STE 300N | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970155703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812862999 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6020 SAN JOSE BLVD W | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322172365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044254393 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2011 | ||||||||
| LastUpdateDate: | 03/15/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | AY1665 | FL | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 003108371A | 05 | GA | MEDICAID | 0035037-00 | 05 | FL | MEDICAID |