Provider Demographics
NPI:1770501850
Name:SELF, LORI TALLEY (CRNA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:TALLEY
Last Name:SELF
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:972-715-9976
Practice Address - Street 1:6606 LBJ FWY
Practice Address - Street 2:SUITE 200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6533
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX640967367500000X
TXAP114602367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179065103Medicaid
TX179065107Medicaid
TX179065110OtherMEDICAID CSHCN
TX8770UGOtherBCBS
TX179065101Medicaid
TX86686UOtherBCBS
TX179065112Medicaid
TX179065109OtherMEDICAID CSHCN
TX179065108Medicaid
TX179065102Medicaid
TXP00719291OtherRAILROAD
TXP01358442OtherRR
TX8G9272Medicare PIN
TX179065108Medicaid
TX179065103Medicaid
TX179065101Medicaid
TX340517YK6UMedicare PIN