Provider Demographics
NPI:1700452752
Name:GOETSCHIUS, SELENA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:SELENA
Middle Name:
Last Name:GOETSCHIUS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 LINDEN LN
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-2451
Mailing Address - Country:US
Mailing Address - Phone:631-796-0003
Mailing Address - Fax:
Practice Address - Street 1:48 LINDEN LN
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-2451
Practice Address - Country:US
Practice Address - Phone:631-796-0003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340872-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse