Provider Demographics
NPI:1053436360
Name:KILLEBREW, MARK C (RN)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:KILLEBREW
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CMR 470
Mailing Address - Street 2:P.O. BOX 4292
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09165
Mailing Address - Country:US
Mailing Address - Phone:328-6695
Mailing Address - Fax:
Practice Address - Street 1:CMR 470
Practice Address - Street 2:BOX 4292
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09165
Practice Address - Country:DE
Practice Address - Phone:328-6695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1071054163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health