Provider Demographics
NPI:1508235029
Name:SKINNER, SERENA (NP)
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:
Last Name:SKINNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 E ELM AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-8321
Mailing Address - Country:US
Mailing Address - Phone:575-914-8422
Mailing Address - Fax:
Practice Address - Street 1:614 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4824
Practice Address - Country:US
Practice Address - Phone:575-622-5705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-15
Last Update Date:2023-03-15
Deactivation Date:2023-03-09
Deactivation Code:
Reactivation Date:2023-03-15
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02778363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner