Provider Demographics
NPI:1144005224
Name:SELF, KERRI RENEE (PMHNP)
Entity type:Individual
Prefix:
First Name:KERRI
Middle Name:RENEE
Last Name:SELF
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-6364
Mailing Address - Country:US
Mailing Address - Phone:575-226-3898
Mailing Address - Fax:575-226-3890
Practice Address - Street 1:405 W 4TH ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6364
Practice Address - Country:US
Practice Address - Phone:575-226-3898
Practice Address - Fax:575-226-3890
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-28
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM75355363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health