=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356755243
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACY ANN SELHORST CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2014
-----------------------------------------------------
Last Update Date | 01/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 322 E MAIN ST
-----------------------------------------------------
City | RUSSELLS POINT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43348-9601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-842-2318
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1001 BELLEFONTAINE AVE
-----------------------------------------------------
City | LIMA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45804-2800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-226-5018
-----------------------------------------------------
Fax | 419-998-4514
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN.CNP.15968
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------