Healthcare Provider Details

I. General information

NPI: 1659854131
Provider Name (Legal Business Name): CAROL LYNN SELBY NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CAROL LYNN MERRILL

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6020 E ARBOR AVE STE 101
MESA AZ
85206-6102
US

IV. Provider business mailing address

3020 E CAMELBACK RD STE 301
PHOENIX AZ
85016-4418
US

V. Phone/Fax

Practice location:
  • Phone: 480-985-1700
  • Fax: 480-396-3659
Mailing address:
  • Phone: 602-264-9100
  • Fax: 602-264-9101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP11588
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: