Healthcare Provider Details

I. General information

NPI: 1104991249
Provider Name (Legal Business Name): JUDITH ANNE SELLE RN MS CNOR CRPFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MEMORIAL DRIVE SUITE #207
DECATUR IL
62526
US

IV. Provider business mailing address

2 MEMORIAL DRIVE SUITE #207
DECATUR IL
62526
US

V. Phone/Fax

Practice location:
  • Phone: 217-876-2784
  • Fax: 217-876-2785
Mailing address:
  • Phone: 217-876-2784
  • Fax: 217-876-2785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: