Provider Demographics
NPI:1699860809
Name:SKINNER, MARK BRADLEY (CNP)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:BRADLEY
Last Name:SKINNER
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 BOWTOWN RD
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-9661
Mailing Address - Country:US
Mailing Address - Phone:740-369-7688
Mailing Address - Fax:740-363-4814
Practice Address - Street 1:824 BOWTOWN RD
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-9661
Practice Address - Country:US
Practice Address - Phone:740-369-7688
Practice Address - Fax:740-363-4814
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI102191041C0700X
OHCOA.15326.NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical