Provider Demographics
NPI:1194791350
Name:SELF, CAROLYN F (FNP)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:F
Last Name:SELF
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 BEALL LN
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-1573
Mailing Address - Country:US
Mailing Address - Phone:541-664-5151
Mailing Address - Fax:
Practice Address - Street 1:1630 SISKIYOU BLVD STE B
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-2423
Practice Address - Country:US
Practice Address - Phone:541-664-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR135416Medicare PIN