Provider Demographics
NPI:1043106982
Name:VANHORN, KIBRA LA'TISE
Entity type:Individual
Prefix:
First Name:KIBRA
Middle Name:LA'TISE
Last Name:VANHORN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIBRA
Other - Middle Name:L
Other - Last Name:VANHORN-WILLIAMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1388 SAINT THOMAS ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-3908
Mailing Address - Country:US
Mailing Address - Phone:269-861-1169
Mailing Address - Fax:
Practice Address - Street 1:185 E MAIN ST STE 405
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-4432
Practice Address - Country:US
Practice Address - Phone:269-588-1119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-17
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1012128225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner