Provider Demographics
NPI:1356590194
Name:SKJERSAA LUKINBEAL, SU CAROLYN (RN, BS, DMIN)
Entity type:Individual
Prefix:DR
First Name:SU
Middle Name:CAROLYN
Last Name:SKJERSAA LUKINBEAL
Suffix:
Gender:F
Credentials:RN, BS, DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16356 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6947
Mailing Address - Country:US
Mailing Address - Phone:541-317-8887
Mailing Address - Fax:541-317-8887
Practice Address - Street 1:389 E. MAIN AVE.
Practice Address - Street 2:LOWER BACK DOOR
Practice Address - City:SISTERS
Practice Address - State:OR
Practice Address - Zip Code:97759
Practice Address - Country:US
Practice Address - Phone:541-317-8887
Practice Address - Fax:541-317-8887
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR00002342RN101YM0800X
OH000023424RN163WP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No163WP0000XNursing Service ProvidersRegistered NursePain Management