1245353416 NPI number — KELLI KEMENAH MAURIC WHNP-BC, APRN

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245353416 NPI number — KELLI KEMENAH MAURIC WHNP-BC, APRN

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

MAURIC

Provider First Name:

KELLI

Provider Middle Name:

KEMENAH

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

WHNP-BC, APRN

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1245353416

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

06/21/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

3772 N MOUNTAINOAK DR

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

EDEN

Provider Business Mailing Address State Name:

UT

Provider Business Mailing Address Postal Code:

84310

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

801-710-2825

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

3772 N MOUNTAINOAK DR

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

EDEN

Provider Business Practice Location Address State Name:

UT

Provider Business Practice Location Address Postal Code:

84310

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

801-710-2825

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

04/10/2007

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 363LW0102X , with the licence number:  NP-07962 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 363LW0102X , with the licence number: 10115460-4405 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 0827627 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: 10115460-4405 . This is a "APRN STATE LICENSURE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: NP-07962 . This is a "OHIO BOARD OF NURSING - CERTIFICATE OF AUTHORITY FOR WHNP-BC LICENSURE - OH" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 000000356173 . This is a "ANTHEM B/C B/S" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 193200000X . This is a "MULTI-SPECIALTY GROUP TAXONOMY BALANCE THE BRAIN PROFESSIONAL CORPORATION" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 363LW0102X . This is a "NURSE PRACTITIONER - WOMENS HEALTH TAXONOMY" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: MAU1-0427-9585 . This is a "NATIONAL CERTIFICATION CORPORATION -USA WOMENS HEALTH NURSE PRACTITIONER WHNP-BC" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 1073270666 . This is a "NPI BALANCE THE BRAIN PROFESSIONAL CORPORATION" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 193200000X . This is a "PROVIDER MULTI-SPECIALTY GROUP - SECONDARY TAXONOMY BALANCE THE BRAIN PROF CORP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 356173 . This is a "BUCKEYE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: I20180403001591 . This is a "PECOS ENROLLMENT ID" identifier . This identifiers is of the category "OTHER".
• Identifier: R04778 . This is a "SUMMACARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 10115460-8900 . This is a "APRN CONTROLLED SUBSTANCE ID" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 104279585 . This is a "NATIONAL CERTIFICATION CORPORATION - WHNP-BC (BOARD CERTIFIED)" identifier . This identifiers is of the category "OTHER".
• Identifier: APP0002758 . This is a "COPIC RRG VIA BAXTER & ASSOCIATES LLC CERTIFICATE OF LIABILITY INSURANCE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: P01571485 . This is a "MEDICARE RR" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: RN266333 . This is a "NATIONAL COUNCIL OF NURSING STATE BOARDS & LICENSURE REGISTERED NURSES" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 740142 . This is a "BUCKEYE MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: APRN.CNP.07962 . This is a "WHNP-BC WITH CERTIFICATE TO PRESCRIBE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".