Provider Demographics
NPI:1194905190
Name:SELF, DOROTHY ROBERTA (ANP)
Entity type:Individual
Prefix:MRS
First Name:DOROTHY
Middle Name:ROBERTA
Last Name:SELF
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:DOROTHY
Other - Middle Name:SMITH
Other - Last Name:SELF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1367
Mailing Address - Street 2:B465
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1367
Mailing Address - Country:US
Mailing Address - Phone:317-962-0745
Mailing Address - Fax:317-962-8349
Practice Address - Street 1:1700 N CAPITOL AVE
Practice Address - Street 2:B465
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202
Practice Address - Country:US
Practice Address - Phone:317-962-0745
Practice Address - Fax:317-962-8349
Is Sole Proprietor?:No
Enumeration Date:2007-11-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000600363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health