Provider Demographics
NPI:1972990828
Name:SKATES, ANDREA LEE (FNP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LEE
Last Name:SKATES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 N 1100 E
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84335-2515
Mailing Address - Country:US
Mailing Address - Phone:205-492-0088
Mailing Address - Fax:
Practice Address - Street 1:3935 N 75 W
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:UT
Practice Address - Zip Code:84318-4111
Practice Address - Country:US
Practice Address - Phone:435-359-0720
Practice Address - Fax:833-992-1993
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-17
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT93804704405363LF0000X
UT93804708900363LF0000X
UT9380470-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1972990828Medicaid