Provider Demographics
NPI:1417285024
Name:SELF, CHRISTI LEE (FNP)
Entity Type:Individual
Prefix:
First Name:CHRISTI
Middle Name:LEE
Last Name:SELF
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CHRISTI
Other - Middle Name:LEE
Other - Last Name:PENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:420 W LONGEST ST
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:IN
Mailing Address - Zip Code:47454-8821
Mailing Address - Country:US
Mailing Address - Phone:812-723-3944
Mailing Address - Fax:812-723-7991
Practice Address - Street 1:5604 E WHITE OAK LN
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IN
Practice Address - Zip Code:47140-8413
Practice Address - Country:US
Practice Address - Phone:812-365-3221
Practice Address - Fax:812-365-9502
Is Sole Proprietor?:No
Enumeration Date:2009-11-20
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28159185A163W00000X
IN71003148A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201075360Medicaid
INM400017841Medicare PIN
INP01213769Medicare PIN