1609544501 NPI number — MRS. JOANNA GRACE SKILES MS

Table of content: MRS. JOANNA GRACE SKILES MS (NPI 1609544501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609544501 NPI number — MRS. JOANNA GRACE SKILES MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SKILES
Provider First Name:
JOANNA
Provider Middle Name:
GRACE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AUGUSTINE
Provider Other First Name:
JOANNA
Provider Other Middle Name:
GRACE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609544501
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
127 ASHLEY CIR APT 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30605-2890
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-962-1749
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2470 DANIELLS BRIDGE RD STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30606-6192
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-389-2950
Provider Business Practice Location Address Fax Number:
706-389-2951
Provider Enumeration Date:
09/03/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SLP012221 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 111804300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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