Basic Information
Provider Information | |||||||||
NPI: | 1255521548 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCKIBBIN | ||||||||
FirstName: | CHILLON | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 610 30TH AVENUE WEST | ||||||||
Address2: | ALEXANDRIA CLINIC | ||||||||
City: | ALEXANDRIA | ||||||||
State: | MN | ||||||||
PostalCode: | 56308 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3207635123 | ||||||||
FaxNumber: | 3207637883 | ||||||||
Practice Location | |||||||||
Address1: | 610 30TH AVENUE WEST | ||||||||
Address2: | ALEXANDRIA CLINIC | ||||||||
City: | ALEXANDRIA | ||||||||
State: | MN | ||||||||
PostalCode: | 56308 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3207635123 | ||||||||
FaxNumber: | 3207637883 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2007 | ||||||||
LastUpdateDate: | 08/09/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | R 156704 7 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   |
ID Information
ID | Type | State | Issuer | Description | P00473736 | 01 | MN | RR MEDICARE | OTHER | 1255521548 | 01 | MN | NPI | OTHER | 1153329 | 01 | MN | AMCB MIDWIFE | OTHER | 638128000 | 05 | MN |   | MEDICAID | R 156704 7 | 01 | MN | MN BOARD OF NRSG | OTHER |