Healthcare Provider Details

I. General information

NPI: 1467263079
Provider Name (Legal Business Name): MISTY DAWN SKODA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2025
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

483 W SEED FARM RD # RC
SACATON AZ
85147-5000
US

IV. Provider business mailing address

890 E KYLE CT
GILBERT AZ
85296-3637
US

V. Phone/Fax

Practice location:
  • Phone: 520-562-3321
  • Fax:
Mailing address:
  • Phone: 602-717-4974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN108665
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: