Provider Demographics
NPI:1407678295
Name:HIBBARD, ELISE NICOLE (MSN APRN PMHNP-BC)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:NICOLE
Last Name:HIBBARD
Suffix:
Gender:F
Credentials:MSN APRN PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23016 HARDING ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2447
Mailing Address - Country:US
Mailing Address - Phone:810-941-1651
Mailing Address - Fax:
Practice Address - Street 1:23016 HARDING ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-2447
Practice Address - Country:US
Practice Address - Phone:810-941-1651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-31
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704274113363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health