Healthcare Provider Details

I. General information

NPI: 1073436002
Provider Name (Legal Business Name): KELLI EISEMANN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 JAMES WAY STE 106
PISMO BEACH CA
93449-4974
US

IV. Provider business mailing address

PO BOX 42
ARROYO GRANDE CA
93421-0042
US

V. Phone/Fax

Practice location:
  • Phone: 805-473-7665
  • Fax:
Mailing address:
  • Phone: 805-489-0623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95040160
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: