Healthcare Provider Details

I. General information

NPI: 1417285024
Provider Name (Legal Business Name): CHRISTI LEE SELF F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTI LEE PENCE F.N.P.

II. Dates (important events)

Enumeration Date: 11/20/2009
Last Update Date: 10/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5604 E WHITE OAK LN
MARENGO IN
47140-8413
US

IV. Provider business mailing address

420 W LONGEST ST
PAOLI IN
47454-8821
US

V. Phone/Fax

Practice location:
  • Phone: 812-365-3221
  • Fax: 812-365-9502
Mailing address:
  • Phone: 812-723-3944
  • Fax: 812-723-7991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28159185A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71003148A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: