Basic Information
| Provider Information | |||||||||
| NPI: | 1265818033 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SKELTON | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | GORDON | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 112 VINCA DR | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391106532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622075345 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1190 N STATE ST STE 2A | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012924292 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2015 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R886220 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7703391 | 05 | MS | MEDICAID |