Healthcare Provider Details

I. General information

NPI: 1063504629
Provider Name (Legal Business Name): MARY L. SKILES R.D., LMNT, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3911 AVENUE B SUITE 1110
SCOTTSBLUFF NE
69361-4617
US

IV. Provider business mailing address

3911 AVENUE B SUITE 1110
SCOTTSBLUFF NE
69361-4617
US

V. Phone/Fax

Practice location:
  • Phone: 308-220-4305
  • Fax: 308-630-2139
Mailing address:
  • Phone: 308-220-4305
  • Fax: 308-630-2139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number503
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number503
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number503
License Number StateNE
# 4
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number503
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: