Healthcare Provider Details

I. General information

NPI: 1710761135
Provider Name (Legal Business Name): ELYSE KELLY CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELYSE EARWOOD

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 N BRENT ST
VENTURA CA
93003-2854
US

IV. Provider business mailing address

287 N DOS CAMINOS AVE
VENTURA CA
93003-1625
US

V. Phone/Fax

Practice location:
  • Phone: 805-948-8300
  • Fax:
Mailing address:
  • Phone: 678-457-3627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number236389
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: