Organization
BALANCE THE BRAIN PROFESSIONAL CORPORATION
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. KELLI KEMENAH MAURIC RN, WHNP-C, BSN, MS (OWNER/ PRESIDENT)
(419) 559-5904
Entity
Organization
Contact information
Practice address
3772 N MOUNTAINOAK DR, EDEN, UT 84310
(419) 559-5904
Mailing address
3772 N MOUNTAINOAK DR, EDEN, UT 84310
(419) 559-5904
Taxonomy
Speciality
Code
Description
License number
State
363LW0102X
Women's Health Nurse Practitioner
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10115460-4405
NP LICENSURE
UT
01
—
363LW0102X
PRIMARY TAXONOMY
OH
01
—
363LW0102X
SECONDARY TAXONOMY
UT
01
—
I20180403001591
PECOS ENROLLMENT ID
—
01
—
NP-07962
BON NP LICENSURE
OH
Enumeration date
11/18/2021
Last updated
11/18/2021
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