Provider Demographics
NPI:1255048674
Name:SELFORS, JOANNA LEE
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:LEE
Last Name:SELFORS
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 1:234 EVANS AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-3802
Mailing Address - Country:US
Mailing Address - Phone:646-713-4618
Mailing Address - Fax:
Practice Address - Street 1:234 EVANS AVE
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-3802
Practice Address - Country:US
Practice Address - Phone:646-713-4618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-04
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY753841163WC0200X
NY433126363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine