Healthcare Provider Details

I. General information

NPI: 1114080934
Provider Name (Legal Business Name): MICHELLE L SKIDMORE RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17400 RESERVATION RD
LA CONNER WA
98257-8801
US

IV. Provider business mailing address

5113 HEATHER DR
ANACORTES WA
98221-3005
US

V. Phone/Fax

Practice location:
  • Phone: 360-466-3167
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI00001414
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: