Provider Demographics
NPI:1255018826
Name:SAMARDZICH, SELENA (FNP)
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:SAMARDZICH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8558 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7032
Mailing Address - Country:US
Mailing Address - Phone:219-392-7084
Mailing Address - Fax:219-703-6854
Practice Address - Street 1:4320 FIR ST UNIT 220
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-3076
Practice Address - Country:US
Practice Address - Phone:219-836-2995
Practice Address - Fax:219-836-4075
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71014743A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300084149Medicaid