Basic Information
| Provider Information | |||||||||
| NPI: | 1578772695 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEKNIGHT-SKINNER | ||||||||
| FirstName: | EXIE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36813 LITTLE LEAF DR | ||||||||
| Address2: | |||||||||
| City: | PALMDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935504478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6614925053 | ||||||||
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| Practice Location | |||||||||
| Address1: | 921 W AVENUE J | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935343443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6619490131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 03/23/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0000CB7733 | 05 | CA | MEDICAID |