Provider Demographics
NPI:1063501880
Name:LANTRY, SELENA ANNE (MD,)
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:ANNE
Last Name:LANTRY
Suffix:
Gender:F
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 WILSON TER STE 130
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4074
Mailing Address - Country:US
Mailing Address - Phone:818-247-2164
Mailing Address - Fax:818-545-0842
Practice Address - Street 1:1505 WILSON TER STE 130
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4074
Practice Address - Country:US
Practice Address - Phone:818-247-2164
Practice Address - Fax:818-545-0842
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55968207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G559681Medicaid
CAF26312Medicare UPIN
CA00G559681Medicaid