Basic Information
| Provider Information | |||||||||
| NPI: | 1659854131 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SELBY | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MERRILL | ||||||||
| OtherFirstName: | CAROL | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3020 E CAMELBACK RD STE 301 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022649100 | ||||||||
| FaxNumber: | 6022649101 | ||||||||
| Practice Location | |||||||||
| Address1: | 6020 E ARBOR AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852066102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809851700 | ||||||||
| FaxNumber: | 4803963659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2018 | ||||||||
| LastUpdateDate: | 09/11/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP11588 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.