Healthcare Provider Details

I. General information

NPI: 1104303205
Provider Name (Legal Business Name): JUSTINE SELF FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2018
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4681 COLLEGE PARK
ROUND ROCK TX
78665-1526
US

IV. Provider business mailing address

7000 N. MOPAC EXPY, STE #420
AUSTIN TX
78731
US

V. Phone/Fax

Practice location:
  • Phone: 512-671-1100
  • Fax:
Mailing address:
  • Phone: 512-482-0045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP138188
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: