Provider Demographics
NPI:1861475238
Name:SELHORST, KATHLEEN S (NP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:S
Last Name:SELHORST
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:LEIPSIC
Mailing Address - State:OH
Mailing Address - Zip Code:45856-9326
Mailing Address - Country:US
Mailing Address - Phone:419-943-2130
Mailing Address - Fax:419-943-2146
Practice Address - Street 1:901 E MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:LEIPSIC
Practice Address - State:OH
Practice Address - Zip Code:45856-9326
Practice Address - Country:US
Practice Address - Phone:419-943-2130
Practice Address - Fax:419-943-2146
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-229364363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000518813OtherANTHEM BC/BS
OH2464033Medicaid
OHP00430695OtherRAILROAD CARE
OH000000518813OtherANTHEM BC/BS
OHQ14106Medicare UPIN
OH2464033Medicaid