MEDICARE: LUANA SELF FNP

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	95002972	CA

General Provider Information

NPI Number	:	1821468497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUANA SELF FNP

Provider Business Mailing Address
First Line	:	1671 W MAIN ST
Second Line	:	SUITE A
City	:	EL CENTRO
State	:	CA
Zip	:	92243-5420
Country	:	US
Telephone Number	:	760-352-3366
Fax Number	:	760-352-3377

Provider Business Practice Location Address
First Line	:	1671 W MAIN ST
Second Line	:	SUITE A
City	:	EL CENTRO
State	:	CA
Zip	:	92243-5420
Country	:	US
Telephone Number	:	760-352-3366
Fax Number	:	760-352-3377

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

Provider Enumeration Date	:	09/25/2015
Last Update Date	:	09/25/2015

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