Provider Demographics
NPI:1033358072
Name:SKINNER, MARY T (ARNP-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:SKINNER
Suffix:
Gender:F
Credentials:ARNP-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:T
Other - Last Name:GEORGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP-C
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0329
Mailing Address - Fax:502-599-0326
Practice Address - Street 1:215 CENTRAL AVE STE 100
Practice Address - Street 2:SUITE 100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40208-1450
Practice Address - Country:US
Practice Address - Phone:502-588-8720
Practice Address - Fax:502-588-8721
Is Sole Proprietor?:No
Enumeration Date:2009-02-16
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5720P363LA2200X, 363LG0600X
KY3005720363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00706702OtherRAILROAD MEDICARE
KY0928411Medicare PIN