Healthcare Provider Details

I. General information

NPI: 1124765714
Provider Name (Legal Business Name): SELINA LOUISE BROADAWAY CPNP-AC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SELINA LOUISE RIBNICK

II. Dates (important events)

Enumeration Date: 05/16/2022
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 DANNY THOMAS PL
MEMPHIS TN
38105-3678
US

IV. Provider business mailing address

848 ADAMS AVE
MEMPHIS TN
38103-2816
US

V. Phone/Fax

Practice location:
  • Phone: 888-226-4343
  • Fax:
Mailing address:
  • Phone: 901-661-3719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number31660
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: