MEDICARE: SELINA HARRISON LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	LPN073776	GA

General Provider Information

NPI Number	:	1710644992
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SELINA HARRISON LPN

Provider Business Mailing Address
First Line	:	PO BOX 9493
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31908-9493
Country	:	US
Telephone Number	:	706-326-7986
Fax Number	:

Provider Business Practice Location Address
First Line	:	5617 PRINCETON AVE STE B
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31904-3483
Country	:	US
Telephone Number	:	706-257-7722
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/22/2021
Last Update Date	:	11/22/2021

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