Basic Information
| Provider Information | |||||||||
| NPI: | 1336611714 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SELF | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 338 VENTURA DR | ||||||||
| Address2: | |||||||||
| City: | BYRON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310088752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789567886 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 640 MARTIN LUTHER KING JR BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312013297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787455455 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2018 | ||||||||
| LastUpdateDate: | 07/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN232828 | GA | N | Nursing Service Providers | Registered Nurse | 363L00000X | RN232828 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.