Provider Demographics
NPI:1699717249
Name:SEELEY, SAMUEL DEAN (CFNP)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:DEAN
Last Name:SEELEY
Suffix:
Gender:M
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:RULEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38771-3227
Mailing Address - Country:US
Mailing Address - Phone:662-756-4024
Mailing Address - Fax:662-756-4114
Practice Address - Street 1:840 N OAK AVE
Practice Address - Street 2:
Practice Address - City:RULEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38771-3227
Practice Address - Country:US
Practice Address - Phone:662-756-4024
Practice Address - Fax:662-756-4114
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR857764363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000124089Medicaid
MSCOO727OtherPART B PHYSICIAN PRO FEE
MS9013863Medicaid
MS253400Medicare ID - Type UnspecifiedCLINIC MEDICARE
MSP07233Medicare UPIN
MS000124089Medicaid