Healthcare Provider Details

I. General information

NPI: 1629506829
Provider Name (Legal Business Name): MARIAH SKELLEY APRN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2017
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5409 AVENUE O
FORT MADISON IA
52627
US

IV. Provider business mailing address

5409 AVENUE O
FORT MADISON IA
52627-9601
US

V. Phone/Fax

Practice location:
  • Phone: 319-376-1130
  • Fax: 319-376-1131
Mailing address:
  • Phone: 319-376-1130
  • Fax: 319-376-1131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number021236
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberG151076
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number393933
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: