Healthcare Provider Details

I. General information

NPI: 1770147233
Provider Name (Legal Business Name): TYLER BLAKE SKELTON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 NOVUS DR STE 2
JOHNSON CITY TN
37604-8237
US

IV. Provider business mailing address

1009 NOVUS DR STE 2
JOHNSON CITY TN
37604-8237
US

V. Phone/Fax

Practice location:
  • Phone: 423-283-0776
  • Fax: 423-283-0549
Mailing address:
  • Phone: 423-283-0776
  • Fax: 423-283-0549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201292
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN25873
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: