Provider Demographics
NPI:1063504629
Name:SKILES, MARY L (RD, LMNT, CDE)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:L
Last Name:SKILES
Suffix:
Gender:F
Credentials:RD, LMNT, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3911 AVENUE B
Mailing Address - Street 2:SUITE 1110
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4617
Mailing Address - Country:US
Mailing Address - Phone:308-220-4305
Mailing Address - Fax:308-630-2139
Practice Address - Street 1:3911 AVENUE B
Practice Address - Street 2:SUITE 1110
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4617
Practice Address - Country:US
Practice Address - Phone:308-220-4305
Practice Address - Fax:308-630-2139
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE503133V00000X, 133VN1004X, 133VN1005X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
274866Medicare PIN
NEP45742Medicare UPIN
NE274866Medicare ID - Type UnspecifiedMEDICARE