Healthcare Provider Details

I. General information

NPI: 1427497429
Provider Name (Legal Business Name): KELLEEN SKONER O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2013
Last Update Date: 06/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 MEDICAL PKWY STE 320
ANNAPOLIS MD
21401-7901
US

IV. Provider business mailing address

2002 MEDICAL PARKWAY SUITE 320
ANNAPOLIS MD
21401
US

V. Phone/Fax

Practice location:
  • Phone: 410-571-8733
  • Fax: 410-571-6309
Mailing address:
  • Phone: 410-571-8733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG002797
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA2357
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: