Provider Demographics
NPI:1346750247
Name:HANNIBAL, SELENA ANN (REGISTERED NURSE)
Entity Type:Individual
Prefix:MS
First Name:SELENA
Middle Name:ANN
Last Name:HANNIBAL
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2301 E MICHIGAN AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-3765
Mailing Address - Country:US
Mailing Address - Phone:517-783-3434
Mailing Address - Fax:517-782-6446
Practice Address - Street 1:2301 E MICHIGAN AVE STE 101
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3765
Practice Address - Country:US
Practice Address - Phone:517-783-3434
Practice Address - Fax:517-782-6446
Is Sole Proprietor?:No
Enumeration Date:2017-10-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704224637163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult