Provider Demographics
NPI:1093779928
Name:SKINNER, SUSAN L (CNM CFNP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:L
Last Name:SKINNER
Suffix:
Gender:F
Credentials:CNM CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 18TH ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103
Mailing Address - Country:US
Mailing Address - Phone:503-325-9131
Mailing Address - Fax:503-325-8797
Practice Address - Street 1:595 18TH ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103
Practice Address - Country:US
Practice Address - Phone:503-325-9131
Practice Address - Fax:503-325-8797
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000038195363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR117572Medicaid
OR117572Medicaid
R94115Medicare UPIN