Provider Demographics
NPI:1982123808
Name:SELEZNEV, KATIE MICHELLE (NP-C)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:MICHELLE
Last Name:SELEZNEV
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 BREWSTER RD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117-2102
Mailing Address - Country:US
Mailing Address - Phone:860-559-1633
Mailing Address - Fax:
Practice Address - Street 1:208 COLLYER ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-1560
Practice Address - Country:US
Practice Address - Phone:401-793-2960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN01682363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner