Basic Information
| Provider Information | |||||||||
| NPI: | 1174712285 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SKELTON | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | AYRE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4120 COLHAM FERRY RD | ||||||||
| Address2: | |||||||||
| City: | WATKINSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306773343 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1199 PRINCE AVE | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065433449 | ||||||||
| FaxNumber: | 7065435744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2007 | ||||||||
| LastUpdateDate: | 01/11/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN159445 | GA | N | Nursing Service Providers | Registered Nurse | 163W00000X | R91530 | SC | N | Nursing Service Providers | Registered Nurse | 367500000X | RN159445 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 714577994A | 05 | GA | MEDICAID |