Healthcare Provider Details

I. General information

NPI: 1336611714
Provider Name (Legal Business Name): HEATHER NICOLE SELF FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2018
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 MARTIN LUTHER KING JR BLVD STE 200
MACON GA
31201-3297
US

IV. Provider business mailing address

338 VENTURA DR
BYRON GA
31008-8752
US

V. Phone/Fax

Practice location:
  • Phone: 478-745-5455
  • Fax:
Mailing address:
  • Phone: 478-956-7886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN232828
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN232828
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: