Provider Demographics
NPI:1962847236
Name:TESSA SKEENS
Entity Type:Organization
Organization Name:TESSA SKEENS
Other - Org Name:INDEPENT PROVIDER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSING ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:TESSA
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:SKEENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-287-8460
Mailing Address - Street 1:1914 PALISADES DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414
Mailing Address - Country:US
Mailing Address - Phone:937-287-8460
Mailing Address - Fax:
Practice Address - Street 1:1914 PALISADES DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414
Practice Address - Country:US
Practice Address - Phone:937-287-8460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3651899251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5074212043-MA-J-01Medicaid