Healthcare Provider Details

I. General information

NPI: 1356204523
Provider Name (Legal Business Name): JANICE SKIDMORE PSW
Entity Type: Individual
Gender:
Sole Proprietor: Y

Provider Other Name: FIADH SKIDMORE

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MARBLE AVE NE
ALBUQUERQUE NM
87106-2058
US

IV. Provider business mailing address

39 VISTA DEL SOL
TIJERAS NM
87059-7917
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-5935
  • Fax:
Mailing address:
  • Phone: 505-272-5935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: