Provider Demographics
NPI:1174903454
Name:MCKIBBIN, AMANDA JO (PTA)
Entity type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:JO
Last Name:MCKIBBIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15237 Z ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-3830
Mailing Address - Country:US
Mailing Address - Phone:712-251-6024
Mailing Address - Fax:
Practice Address - Street 1:4330 S 144TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-1051
Practice Address - Country:US
Practice Address - Phone:402-614-4000
Practice Address - Fax:402-614-4001
Is Sole Proprietor?:No
Enumeration Date:2015-06-02
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004851225200000X
NE1152225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant