Healthcare Provider Details

I. General information

NPI: 1538750237
Provider Name (Legal Business Name): MADDISON RAE SKRETTEBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2021
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 PINELLAS ST STE 400
CLEARWATER FL
33756-3356
US

IV. Provider business mailing address

455 PINELLAS ST STE 400
CLEARWATER FL
33756-3356
US

V. Phone/Fax

Practice location:
  • Phone: 727-445-1911
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9117470
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: