Provider Demographics
NPI:1689714636
Name:SKJOLDAL, MARY JO (ROM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:SKJOLDAL
Suffix:
Gender:F
Credentials:ROM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:37 DRAGSTRIP RD
Mailing Address - Street 2:
Mailing Address - City:CATAWISSA
Mailing Address - State:PA
Mailing Address - Zip Code:17820-8712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:227 CENTER ST
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1701
Practice Address - Country:US
Practice Address - Phone:570-204-6358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAK000673171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist