Provider Demographics
NPI:1104385301
Name:SELBY, KISHA MARY
Entity Type:Individual
Prefix:
First Name:KISHA
Middle Name:MARY
Last Name:SELBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8221 TOWNSHIP DR
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5417
Mailing Address - Country:US
Mailing Address - Phone:410-258-8599
Mailing Address - Fax:
Practice Address - Street 1:7141 SECURITY BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21244-1811
Practice Address - Country:US
Practice Address - Phone:443-663-6420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR223110163WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0200XNursing Service ProvidersRegistered NurseOncology