Provider Demographics
NPI:1386248045
Name:MUSGROVE, SELENA D
Entity type:Individual
Prefix:MRS
First Name:SELENA
Middle Name:D
Last Name:MUSGROVE
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 1:20 DEER HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-5995
Mailing Address - Country:US
Mailing Address - Phone:304-694-3239
Mailing Address - Fax:
Practice Address - Street 1:20 DEER HAVEN DR
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-5995
Practice Address - Country:US
Practice Address - Phone:304-694-3239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV207653Medicaid