Provider Demographics
NPI:1891325411
Name:SKINNER, NICOLE (PHARMD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SKINNER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 S PINE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1914
Practice Address - Country:US
Practice Address - Phone:262-763-7177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15924-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist