Provider Demographics
NPI:1477313567
Name:WIMBERLY, SKYLAR BROOKE
Entity Type:Individual
Prefix:
First Name:SKYLAR
Middle Name:BROOKE
Last Name:WIMBERLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 COUNTRY RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:ELKLAND
Mailing Address - State:MO
Mailing Address - Zip Code:65644-7304
Mailing Address - Country:US
Mailing Address - Phone:417-733-3208
Mailing Address - Fax:
Practice Address - Street 1:1000 E US HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:MONETT
Practice Address - State:MO
Practice Address - Zip Code:65708-1698
Practice Address - Country:US
Practice Address - Phone:417-235-3144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024009559363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical