Provider Demographics
NPI:1346850278
Name:SELMON, AMY MELISSA (NP)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:MELISSA
Last Name:SELMON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 NORTH PEARL STREET
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852
Mailing Address - Country:US
Mailing Address - Phone:662-656-0183
Mailing Address - Fax:
Practice Address - Street 1:904 NORTH PEARL STREET
Practice Address - Street 2:
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852
Practice Address - Country:US
Practice Address - Phone:662-656-0183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS878054163W00000X
MS903884363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty