Provider Demographics
NPI:1790476125
Name:SAMUEL, SELVA SUNIL (DNP, CRNP, RN)
Entity Type:Individual
Prefix:
First Name:SELVA
Middle Name:SUNIL
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:DNP, CRNP, RN
Other - Prefix:
Other - First Name:SELVA
Other - Middle Name:
Other - Last Name:KORUTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18 ROCKING HORSE WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-2561
Mailing Address - Country:US
Mailing Address - Phone:215-317-6665
Mailing Address - Fax:
Practice Address - Street 1:825 TOWN CENTER DR STE 152
Practice Address - Street 2:
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-1793
Practice Address - Country:US
Practice Address - Phone:215-741-3510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP026627363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily