Provider Demographics
NPI:1518698059
Name:SKIPWORTH, MARY BROOK (APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BROOK
Last Name:SKIPWORTH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-858-6655
Mailing Address - Fax:270-858-4607
Practice Address - Street 1:102 RHODES ST
Practice Address - Street 2:
Practice Address - City:GAMALIEL
Practice Address - State:KY
Practice Address - Zip Code:42140-8942
Practice Address - Country:US
Practice Address - Phone:270-457-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3017571363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100821890Medicaid