Provider Demographics
NPI:1205500170
Name:SELECON, MACDANA
Entity type:Individual
Prefix:MISS
First Name:MACDANA
Middle Name:
Last Name:SELECON
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 1:268 BALD EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-1054
Mailing Address - Country:US
Mailing Address - Phone:618-531-2053
Mailing Address - Fax:
Practice Address - Street 1:1079 SUNRISE AVE STE B-244
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-7009
Practice Address - Country:US
Practice Address - Phone:925-338-1430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2024-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95204457163W00000X
CA95029190363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse