Healthcare Provider Details

I. General information

NPI: 1568187821
Provider Name (Legal Business Name): CRYSTAL JEAN SKINNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 10/10/2022
Certification Date: 10/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8220 NATURES WAY
LAKEWOOD RANCH FL
34202-4204
US

IV. Provider business mailing address

4046 PALAU DR
SARASOTA FL
34241-5843
US

V. Phone/Fax

Practice location:
  • Phone: 904-618-3778
  • Fax:
Mailing address:
  • Phone: 708-670-6973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number24804
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: