Provider Demographics
NPI:1821602582
Name:SELF, KRISTEN LEE
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:LEE
Last Name:SELF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5839 BRANDONS WAY
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-7301
Mailing Address - Country:US
Mailing Address - Phone:703-509-3529
Mailing Address - Fax:
Practice Address - Street 1:5755 CEDAR LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2999
Practice Address - Country:US
Practice Address - Phone:410-884-4888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRN199892363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics