Provider Demographics
NPI:1134993041
Name:ROGGEVEEN, SELENA JOYCE (NP)
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:JOYCE
Last Name:ROGGEVEEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SELENA
Other - Middle Name:JOYCE
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:11161 RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-8564
Practice Address - Country:US
Practice Address - Phone:219-662-9424
Practice Address - Fax:219-662-7465
Is Sole Proprietor?:No
Enumeration Date:2023-11-10
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28161718A163W00000X
IN71014849A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse