Provider Demographics
NPI:1669744876
Name:SELAK, DEBORAH HENDERSON (ARNP)
Entity type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:HENDERSON
Last Name:SELAK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1750 FRAYSER BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38127-6439
Mailing Address - Country:US
Mailing Address - Phone:901-358-0368
Mailing Address - Fax:901-358-9010
Practice Address - Street 1:1750 FRAYSER BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38127-6439
Practice Address - Country:US
Practice Address - Phone:901-358-0368
Practice Address - Fax:901-358-9010
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14290364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1609891654Medicare PIN
TNA98721Medicare UPIN