Provider Demographics
NPI:1841779097
Name:VALYAN, SELISA MALVO
Entity Type:Individual
Prefix:MRS
First Name:SELISA
Middle Name:MALVO
Last Name:VALYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SELISA
Other - Middle Name:DESEREE
Other - Last Name:VALYAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:5656 PINEWOOD DR W
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-7576
Mailing Address - Country:US
Mailing Address - Phone:337-499-3030
Mailing Address - Fax:
Practice Address - Street 1:524 DR MICHAEL DEBAKEY DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5725
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0225513363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA$$$$$$$$$Medicaid