Provider Demographics
NPI:1124881883
Name:SELNER, MANDY CHERIE
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:CHERIE
Last Name:SELNER
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 95590
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-0590
Mailing Address - Country:US
Mailing Address - Phone:801-352-9500
Mailing Address - Fax:801-352-7976
Practice Address - Street 1:125 BAPTIST WAY STE 4B
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2274
Practice Address - Country:US
Practice Address - Phone:448-227-6350
Practice Address - Fax:850-437-8719
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11030957363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty