Basic Information
| Provider Information | |||||||||
| NPI: | 1366632523 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SKELLY | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | DANIELLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 317 E 20TH ST | ||||||||
| Address2: | |||||||||
| City: | ELK CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736446902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862132879 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10321 N 2274 RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736017521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803313300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2007 | ||||||||
| LastUpdateDate: | 12/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 102664 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000130400 | 05 | FL | MEDICAID |