Healthcare Provider Details

I. General information

NPI: 1033724372
Provider Name (Legal Business Name): KELSEY LAUREN ENNIS CNM, WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 03/15/2024
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1417 2ND ST STE D
SANTA MONICA CA
90401-2399
US

IV. Provider business mailing address

1417 2ND ST STE D
SANTA MONICA CA
90401-2399
US

V. Phone/Fax

Practice location:
  • Phone: 646-650-5337
  • Fax: 646-871-6820
Mailing address:
  • Phone: 918-857-8740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR0133249
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number0024180210
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: