Provider Demographics
NPI:1467737189
Name:SKELLY, ELIZABETH ELLEN (APN)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ELLEN
Last Name:SKELLY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ELLEN
Other - Last Name:CERRENTANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:902 LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3597
Mailing Address - Country:US
Mailing Address - Phone:719-557-5855
Mailing Address - Fax:719-557-4652
Practice Address - Street 1:902 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3597
Practice Address - Country:US
Practice Address - Phone:719-557-5855
Practice Address - Fax:719-557-4652
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008690363LF0000X
CO0992400363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209008690OtherILLINOIS LICENSE
IL209008690OtherILLINOIS LICENSE