Healthcare Provider Details

I. General information

NPI: 1972503829
Provider Name (Legal Business Name): TANYA R SELLERS-HANNIBAL DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TANYA ROCHELLE SELLERS DPM

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 07/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10085 RED RUN BLVD SUITE 305
OWINGS MILLS MD
21117-4836
US

IV. Provider business mailing address

10085 RED RUN BLVD SUITE 305
OWINGS MILLS MD
21117-4836
US

V. Phone/Fax

Practice location:
  • Phone: 410-581-8331
  • Fax: 410-581-8332
Mailing address:
  • Phone: 410-581-8331
  • Fax: 410-581-8332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number01173
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number01173
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: