Provider Demographics
NPI:1063052116
Name:PEVAHOUSE, SELENA RENEE
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:RENEE
Last Name:PEVAHOUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 54
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:TN
Mailing Address - Zip Code:38425-0054
Mailing Address - Country:US
Mailing Address - Phone:731-607-1007
Mailing Address - Fax:
Practice Address - Street 1:110 MILLER DRIVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:TN
Practice Address - Zip Code:38425
Practice Address - Country:US
Practice Address - Phone:731-607-1007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26817363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health