Provider Demographics
NPI:1588065767
Name:HIBDON, ELLEN GRACE
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:GRACE
Last Name:HIBDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 E 200 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2110
Mailing Address - Country:US
Mailing Address - Phone:801-322-3222
Mailing Address - Fax:
Practice Address - Street 1:607 E 200 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2110
Practice Address - Country:US
Practice Address - Phone:801-322-3222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker