Provider Demographics
NPI:1336923192
Name:SELAH MEDICAL, LLC
Entity type:Organization
Organization Name:SELAH MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MARTINO
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:307-640-0273
Mailing Address - Street 1:920 CREIGHTON ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-3229
Mailing Address - Country:US
Mailing Address - Phone:307-640-0273
Mailing Address - Fax:307-514-0231
Practice Address - Street 1:920 CREIGHTON ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-3229
Practice Address - Country:US
Practice Address - Phone:307-640-0273
Practice Address - Fax:307-514-0231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-22
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty