Healthcare Provider Details

I. General information

NPI: 1104385301
Provider Name (Legal Business Name): KISHA MARY SELBY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 03/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7141 SECURITY BLVD
BALTIMORE MD
21244-1811
US

IV. Provider business mailing address

8221 TOWNSHIP DR
OWINGS MILLS MD
21117-5417
US

V. Phone/Fax

Practice location:
  • Phone: 443-663-6420
  • Fax:
Mailing address:
  • Phone: 410-258-8599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License NumberR223110
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: