Provider Demographics
NPI:1992922041
Name:SKINNER, ERNESTINE
Entity type:Individual
Prefix:MRS
First Name:ERNESTINE
Middle Name:
Last Name:SKINNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 PARK AVE
Mailing Address - Street 2:HENDERSON
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-3101
Mailing Address - Country:US
Mailing Address - Phone:252-430-1186
Mailing Address - Fax:
Practice Address - Street 1:845 PARK AVE
Practice Address - Street 2:HENDERSON
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-3101
Practice Address - Country:US
Practice Address - Phone:252-430-1186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001190133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2993072Medicare ID - Type Unspecified