Healthcare Provider Details

I. General information

NPI: 1245866805
Provider Name (Legal Business Name): SELBY MARIE CHERIAN DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2020
Last Update Date: 04/18/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N SAINT CLAIR ST STE 19-100
CHICAGO IL
60611-5969
US

IV. Provider business mailing address

675 N SAINT CLAIR ST STE 19-100
CHICAGO IL
60611-5969
US

V. Phone/Fax

Practice location:
  • Phone: 312-664-3278
  • Fax: 312-695-5774
Mailing address:
  • Phone: 312-664-3278
  • Fax: 312-695-5774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209021106
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041446654
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: