Provider Demographics
NPI:1033724372
Name:ENNIS, KELSEY LAUREN (CNM, WHNP-BC)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:LAUREN
Last Name:ENNIS
Suffix:
Gender:F
Credentials:CNM, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 2ND ST STE D
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-2399
Mailing Address - Country:US
Mailing Address - Phone:918-857-8740
Mailing Address - Fax:
Practice Address - Street 1:1417 2ND ST STE D
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2399
Practice Address - Country:US
Practice Address - Phone:646-650-5337
Practice Address - Fax:646-871-6820
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0133249163W00000X
367A00000X
VA0024180210363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No163W00000XNursing Service ProvidersRegistered Nurse
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife