Healthcare Provider Details

I. General information

NPI: 1740111814
Provider Name (Legal Business Name): CANNAMOMMY HOLISTIC BOTANICALS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 CRISSY WAY
FORTUNA CA
95540-3152
US

IV. Provider business mailing address

824 CRISSY WAY
FORTUNA CA
95540-3152
US

V. Phone/Fax

Practice location:
  • Phone: 970-471-9251
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name: KELLY USBORNE BRUCE
Title or Position: CEO
Credential: DOULA
Phone: 970-471-9251