Basic Information
| Provider Information | |||||||||
| NPI: | 1417285024 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SELF | ||||||||
| FirstName: | CHRISTI | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | F.N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PENCE | ||||||||
| OtherFirstName: | CHRISTI | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | F.N.P. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 420 W LONGEST ST | ||||||||
| Address2: | |||||||||
| City: | PAOLI | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474548821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127233944 | ||||||||
| FaxNumber: | 8127237991 | ||||||||
| Practice Location | |||||||||
| Address1: | 5604 E WHITE OAK LN | ||||||||
| Address2: | |||||||||
| City: | MARENGO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471408413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123653221 | ||||||||
| FaxNumber: | 8123659502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2009 | ||||||||
| LastUpdateDate: | 10/24/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 28159185A | IN | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 71003148A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 201075360 | 05 | IN | MEDICAID |