1104991249 NPI number — MS. JUDITH ANNE SELLE RN MS CNOR CRPFA

Table of content: MS. JUDITH ANNE SELLE RN MS CNOR CRPFA (NPI 1104991249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104991249 NPI number — MS. JUDITH ANNE SELLE RN MS CNOR CRPFA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SELLE
Provider First Name:
JUDITH
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RN MS CNOR CRPFA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104991249
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 MEMORIAL DRIVE
Provider Second Line Business Mailing Address:
SUITE #207
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62526
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-876-2784
Provider Business Mailing Address Fax Number:
217-876-2785

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 MEMORIAL DRIVE
Provider Second Line Business Practice Location Address:
SUITE #207
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-876-2784
Provider Business Practice Location Address Fax Number:
217-876-2785
Provider Enumeration Date:
11/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WR0006X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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