Provider Demographics
NPI:1598137929
Name:NELSON, SELENE
Entity Type:Individual
Prefix:
First Name:SELENE
Middle Name:
Last Name:NELSON
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 1:53 GATES CT
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-9716
Mailing Address - Country:US
Mailing Address - Phone:732-242-9507
Mailing Address - Fax:
Practice Address - Street 1:53 GATES CT
Practice Address - Street 2:
Practice Address - City:MATAWAN
Practice Address - State:NJ
Practice Address - Zip Code:07747-9716
Practice Address - Country:US
Practice Address - Phone:732-242-9507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-25
Last Update Date:2015-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program