Provider Demographics
NPI:1992349286
Name:HAIRSTON, SELENA
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:HAIRSTON
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 1:1800 S HANOVER ST APT 308
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-4984
Mailing Address - Country:US
Mailing Address - Phone:973-666-1880
Mailing Address - Fax:
Practice Address - Street 1:1800 N CHARLES ST STE 900
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-5987
Practice Address - Country:US
Practice Address - Phone:443-300-6705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-30
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0033560363LP0808X
OH412687163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse