Healthcare Provider Details

I. General information

NPI: 1477313567
Provider Name (Legal Business Name): SKYLAR BROOKE WIMBERLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2024
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 COUNTRY RIDGE LN
ELKLAND MO
65644-7304
US

IV. Provider business mailing address

25 COUNTRY RIDGE LN
ELKLAND MO
65644-7304
US

V. Phone/Fax

Practice location:
  • Phone: 417-733-3208
  • Fax:
Mailing address:
  • Phone: 417-733-3208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number11441
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: