MEDICARE: KELLY A SKINNER RN, MSN, FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209019575	IL

General Provider Information

NPI Number	:	1679113062
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY A SKINNER RN, MSN, FNP-BC

Provider Business Mailing Address
First Line	:	936 E 93RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-7814
Country	:	US
Telephone Number	:	773-731-5395
Fax Number	:	773-336-5545

Provider Business Practice Location Address
First Line	:	936 E 93RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-7814
Country	:	US
Telephone Number	:	773-731-5395
Fax Number	:	773-336-5545

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/14/2020
Last Update Date	:	03/15/2022

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