Provider Demographics
NPI:1104153774
Name:STOOKSBURY, SELICIA MADONNA (LPN)
Entity type:Individual
Prefix:MRS
First Name:SELICIA
Middle Name:MADONNA
Last Name:STOOKSBURY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:TN
Mailing Address - Zip Code:37716-3143
Mailing Address - Country:US
Mailing Address - Phone:865-425-8800
Mailing Address - Fax:865-457-4252
Practice Address - Street 1:710 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:TN
Practice Address - Zip Code:37716-3143
Practice Address - Country:US
Practice Address - Phone:865-425-8800
Practice Address - Fax:865-457-4252
Is Sole Proprietor?:No
Enumeration Date:2009-11-03
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000070124164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse