Provider Demographics
NPI:1427423730
Name:SELFRIDGE, ANN
Entity type:Individual
Prefix:MISS
First Name:ANN
Middle Name:
Last Name:SELFRIDGE
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 1:1698 VICTORY BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314
Mailing Address - Country:US
Mailing Address - Phone:347-621-6174
Mailing Address - Fax:
Practice Address - Street 1:1698 VICTORY BOULEVARD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314
Practice Address - Country:US
Practice Address - Phone:347-621-6174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-11
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care