Healthcare Provider Details

I. General information

NPI: 1164815676
Provider Name (Legal Business Name): KELSEY HOUSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2015
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3065 TOWN TER
NORTH PORT FL
34286-4363
US

IV. Provider business mailing address

1498 PACIFIC AVE STE 400
TACOMA WA
98402-4208
US

V. Phone/Fax

Practice location:
  • Phone: 239-989-7375
  • Fax:
Mailing address:
  • Phone: 855-768-6363
  • Fax: 253-682-1714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberARNP9268237
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number4704318096
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: