Healthcare Provider Details

I. General information

NPI: 1578143459
Provider Name (Legal Business Name): HAILEY SELLEK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6051 W EMERALD ST
BOISE ID
83704-8969
US

IV. Provider business mailing address

6051 W EMERALD ST
BOISE ID
83704-8969
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-5100
  • Fax: 208-302-5155
Mailing address:
  • Phone: 217-249-1077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number103031-875
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.167759
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4671896
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: