Provider Demographics
NPI:1659619526
Name:SKINNER, AUDRA (LMT)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:SKINNER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1659 NE MARKET DR
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-3867
Mailing Address - Country:US
Mailing Address - Phone:503-465-9100
Mailing Address - Fax:
Practice Address - Street 1:1659 NE MARKET DR
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:OR
Practice Address - Zip Code:97024-3867
Practice Address - Country:US
Practice Address - Phone:503-465-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13515225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist