Provider Demographics
NPI:1821503814
Name:MOORE, MARY SKYLAR
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SKYLAR
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 SHARON DR
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-6435
Mailing Address - Country:US
Mailing Address - Phone:580-370-6767
Mailing Address - Fax:
Practice Address - Street 1:2403 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-6027
Practice Address - Country:US
Practice Address - Phone:405-260-3441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator