Provider Demographics
NPI:1174146757
Name:SKIDMORE, ANDREA NICOLE (LPN)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:NICOLE
Last Name:SKIDMORE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 STEWART ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-6030
Mailing Address - Country:US
Mailing Address - Phone:740-405-1184
Mailing Address - Fax:
Practice Address - Street 1:1060 STEWART ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-6030
Practice Address - Country:US
Practice Address - Phone:740-405-1184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.154288.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH09161988OtherMEDICARE
OH09161988Medicaid