Provider Demographics
NPI:1265420061
Name:SKELLY, THERESA ANNE (PA-C)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ANNE
Last Name:SKELLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NUVANCE HEALTH
Mailing Address - Street 2:1351 ROUTE 55, SUITE 200
Mailing Address - City:LAGRANGEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12540
Mailing Address - Country:US
Mailing Address - Phone:845-475-9500
Mailing Address - Fax:
Practice Address - Street 1:NORTHERN DUTCHESS HOSPITAL
Practice Address - Street 2:6511 SPRING BROOK AVENUE
Practice Address - City:RHINEBECK
Practice Address - State:NY
Practice Address - Zip Code:12572
Practice Address - Country:US
Practice Address - Phone:845-876-3001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025130225100000X
CT2947363A00000X
NY014910363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P97006Medicare UPIN
NYA400057930Medicare PIN