Provider Demographics
NPI:1578863841
Name:SELF, DEANA MARIE (FNP-C)
Entity Type:Individual
Prefix:
First Name:DEANA
Middle Name:MARIE
Last Name:SELF
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25310 S STATE ROUTE K
Mailing Address - Street 2:
Mailing Address - City:HARRISONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64701-9179
Mailing Address - Country:US
Mailing Address - Phone:606-200-6638
Mailing Address - Fax:
Practice Address - Street 1:2820 E ROCK HAVEN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-4411
Practice Address - Country:US
Practice Address - Phone:816-380-3582
Practice Address - Fax:816-380-6964
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010038269363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1578863841Medicaid
MO1578863841Medicaid
MOK44000004Medicare PIN