Healthcare Provider Details

I. General information

NPI: 1457002990
Provider Name (Legal Business Name): KELSEY MARIE DENISON PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2022
Last Update Date: 08/26/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 E CLARK ST STE 330
POCATELLO ID
83201-3357
US

IV. Provider business mailing address

7201 N BEEHIVE RD
POCATELLO ID
83201-9119
US

V. Phone/Fax

Practice location:
  • Phone: 208-478-9081
  • Fax:
Mailing address:
  • Phone: 208-252-1539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number2021185711
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number49743
License Number StateWY
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71737
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: