Provider Demographics
NPI:1497840292
Name:ANKARBERG, SELENA JEANETTE (FNP)
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:JEANETTE
Last Name:ANKARBERG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 871
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-0871
Mailing Address - Country:US
Mailing Address - Phone:208-549-0211
Mailing Address - Fax:208-549-0104
Practice Address - Street 1:683 E 3RD ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-2248
Practice Address - Country:US
Practice Address - Phone:208-549-0211
Practice Address - Fax:208-549-0104
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-730A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807397200Medicaid
ID807397200Medicaid
1345337Medicare ID - Type Unspecified
ID1345337Medicare PIN
ID080102428Medicare PIN