Provider Demographics
NPI:1174090062
Name:MCKIBLE, KENDRA (PA)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:MCKIBLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 PLATTS AVE
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03109-4721
Mailing Address - Country:US
Mailing Address - Phone:603-748-1883
Mailing Address - Fax:
Practice Address - Street 1:9 WASHINGTON PL STE 204
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6750
Practice Address - Country:US
Practice Address - Phone:603-625-5744
Practice Address - Fax:603-606-3049
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NH1478363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program