Healthcare Provider Details

I. General information

NPI: 1154895209
Provider Name (Legal Business Name): SKIN ENVY DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2019
Last Update Date: 01/13/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3140 ELK LN STE 600
FREMONT NE
68025-8650
US

IV. Provider business mailing address

3140 ELK LN STE 600
FREMONT NE
68025-8650
US

V. Phone/Fax

Practice location:
  • Phone: 402-936-6198
  • Fax: 402-816-4402
Mailing address:
  • Phone: 402-936-6198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DEBRA LYNN BAKER
Title or Position: OWNER/NP
Credential: NP
Phone: 402-936-6198