Provider Demographics
NPI:1902125727
Name:SELKING, AMANDA MARIE (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MARIE
Last Name:SELKING
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 TOWER DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:IN
Mailing Address - Zip Code:46772-9362
Mailing Address - Country:US
Mailing Address - Phone:260-692-6163
Mailing Address - Fax:260-728-3949
Practice Address - Street 1:205 TOWER DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:IN
Practice Address - Zip Code:46772-9362
Practice Address - Country:US
Practice Address - Phone:260-692-6163
Practice Address - Fax:260-728-3949
Is Sole Proprietor?:No
Enumeration Date:2010-05-18
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28160341A163W00000X
IN71003269A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200989710Medicaid
IN200989710Medicaid