Healthcare Provider Details

I. General information

NPI: 1952773764
Provider Name (Legal Business Name): MELISSA J SKINNER AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2015
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4805 NE GLISAN ST
PORTLAND OR
97213-2933
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-2392
  • Fax:
Mailing address:
  • Phone: 503-215-6494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number201341076RN
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number202108974NP-PP
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number202108974NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: