Healthcare Provider Details

I. General information

NPI: 1033595509
Provider Name (Legal Business Name): LEE TAYLOR SKELTON DNP, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 08/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 E BAKER ST
INDIANOLA MS
38751-2450
US

IV. Provider business mailing address

706 W GRESHAM ST
INDIANOLA MS
38751-2046
US

V. Phone/Fax

Practice location:
  • Phone: 662-887-6000
  • Fax:
Mailing address:
  • Phone: 662-931-2256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR877686
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: