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General NPI Number Information
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NPI Number | 1073270666
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Entity Type | Organization
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Legal Business Name | BALANCE THE BRAIN PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 11/18/2021
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Last Update Date | 11/18/2021
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Provider Practice Location Address
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Address Line | 3772 N MOUNTAINOAK DR
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City | EDEN
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State | UT
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Zip | 84310
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Country | US
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Telephone | 419-559-5904
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Fax |
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Provider Business Mailing Address
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Address Line | 3772 N MOUNTAINOAK DR
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City | EDEN
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State | UT
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Zip | 84310
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Country | US
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Telephone | 419-559-5904
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Fax |
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Authorized Official
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Title or Position | OWNER/ PRESIDENT
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Name | MRS. KELLI KEMENAH MAURIC
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Credential | RN, WHNP-C, BSN, MS
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Telephone | 419-559-5904
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LW0102X
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Taxonomy Name | Women's Health Nurse Practitioner
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License Number |
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License Number State |
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