Provider Demographics
NPI:1164688990
Name:SELVAGGIO, TARA (RN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:SELVAGGIO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14608-1410
Mailing Address - Country:US
Mailing Address - Phone:585-368-8847
Mailing Address - Fax:
Practice Address - Street 1:81 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14608-1410
Practice Address - Country:US
Practice Address - Phone:585-368-8847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY471463163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult