Provider Demographics
NPI:1508233651
Name:DATTOLI, SELENA NICOLE (APRN, FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:SELENA
Middle Name:NICOLE
Last Name:DATTOLI
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 S NOLAND RD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-3344
Mailing Address - Country:US
Mailing Address - Phone:866-389-2727
Mailing Address - Fax:866-389-2727
Practice Address - Street 1:3825 S NOLAND RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-3344
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:866-389-2727
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2019-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015014596363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily