Provider Demographics
NPI:1124595327
Name:SKINNER, GRACE SKOOG (RD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:SKOOG
Last Name:SKINNER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 SW 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-6504
Mailing Address - Country:US
Mailing Address - Phone:352-402-5167
Mailing Address - Fax:352-402-5157
Practice Address - Street 1:1500 SW 1ST AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-6504
Practice Address - Country:US
Practice Address - Phone:352-402-5167
Practice Address - Fax:352-402-5157
Is Sole Proprietor?:No
Enumeration Date:2018-10-26
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND820133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered