MEDICARE: VERLECIA SELF

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	2016007862	VA

General Provider Information

NPI Number	:	1255885638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VERLECIA SELF

Provider Business Mailing Address
First Line	:	11344 CHESTER GARDEN CIR
Second Line	:
City	:	CHESTER
State	:	VA
Zip	:	23831-1795
Country	:	US
Telephone Number	:	225-747-0090
Fax Number	:

Provider Business Practice Location Address
First Line	:	221 E HUNDRED RD
Second Line	:
City	:	CHESTER
State	:	VA
Zip	:	23836-2613
Country	:	US
Telephone Number	:	866-389-2727
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/15/2016
Last Update Date	:	08/15/2016

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