Provider Demographics
NPI:1003371527
Name:SKIDMORE, REAGAN CLAIRE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:REAGAN
Middle Name:CLAIRE
Last Name:SKIDMORE
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17017 CULPS BLUFF AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-3339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 GALLOWAY DRIVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70402-3339
Practice Address - Country:US
Practice Address - Phone:985-549-5133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
LA3239472255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program