Healthcare Provider Details

I. General information

NPI: 1497076814
Provider Name (Legal Business Name): MICHELLE MARIE SKINNER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 09/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 BRANDERMILL BLVD
GAMBRILLS MD
21054-1690
US

IV. Provider business mailing address

PO BOX 12622
BELFAST ME
04915-4017
US

V. Phone/Fax

Practice location:
  • Phone: 410-721-1507
  • Fax: 410-721-1510
Mailing address:
  • Phone: 443-481-6576
  • Fax: 443-481-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2747
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: