Provider Demographics
NPI:1770147233
Name:SKELTON, TYLER BLAKE (RN)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:BLAKE
Last Name:SKELTON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 NOVUS DR STE 2
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-8237
Mailing Address - Country:US
Mailing Address - Phone:423-283-0776
Mailing Address - Fax:423-283-0549
Practice Address - Street 1:1009 NOVUS DR STE 2
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-8237
Practice Address - Country:US
Practice Address - Phone:423-283-0776
Practice Address - Fax:423-283-0549
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN201292163W00000X
TNAPN25873367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse