Provider Demographics
NPI:1639320641
Name:SELBY, CASSANDRA DAWN (RN, BSN, CNM, ARNP)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:DAWN
Last Name:SELBY
Suffix:
Gender:F
Credentials:RN, BSN, CNM, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 HARTFORD ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2138
Mailing Address - Country:US
Mailing Address - Phone:765-742-1567
Mailing Address - Fax:765-429-2700
Practice Address - Street 1:2316 SOUTH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2971
Practice Address - Country:US
Practice Address - Phone:765-742-1567
Practice Address - Fax:765-429-2700
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09000357A367A00000X
CO13025363LX0001X
COAPN.0013025-CNM367A00000X
MO2018038903367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300045852Medicaid