Provider Demographics
NPI:1689220220
Name:CARMONA, SELENA G
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:G
Last Name:CARMONA
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 1:216 HOOK RD
Mailing Address - Street 2:
Mailing Address - City:HONEA PATH
Mailing Address - State:SC
Mailing Address - Zip Code:29654-7819
Mailing Address - Country:US
Mailing Address - Phone:864-865-1008
Mailing Address - Fax:800-340-0223
Practice Address - Street 1:216 HOOK RD
Practice Address - Street 2:
Practice Address - City:HONEA PATH
Practice Address - State:SC
Practice Address - Zip Code:29654-7819
Practice Address - Country:US
Practice Address - Phone:864-865-1008
Practice Address - Fax:800-340-0223
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC103724712OtherDRIVERS LICENSE