Provider Demographics
NPI:1710460969
Name:SKILES, LAURA WINGO (PT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:WINGO
Last Name:SKILES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 MAPLETON RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-5345
Mailing Address - Country:US
Mailing Address - Phone:904-399-3218
Mailing Address - Fax:
Practice Address - Street 1:1212 MAPLETON RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5345
Practice Address - Country:US
Practice Address - Phone:904-399-3218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18450225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist