Healthcare Provider Details

I. General information

NPI: 1144648528
Provider Name (Legal Business Name): SELENA ANTHONY WHNP-BC, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 04/04/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 HOSPITAL SOUTH DR STE 301
AUSTELL GA
30106-8116
US

IV. Provider business mailing address

4400 BROWNSVILLE RD STE 105-3620
POWDER SPRINGS GA
30127-3199
US

V. Phone/Fax

Practice location:
  • Phone: 770-819-9211
  • Fax:
Mailing address:
  • Phone: 770-819-9211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN198374
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN198374
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberRN1981374
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: