Provider Demographics
NPI:1073270666
Name:BALANCE THE BRAIN PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:BALANCE THE BRAIN PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:KEMENAH
Authorized Official - Last Name:MAURIC
Authorized Official - Suffix:
Authorized Official - Credentials:RN, WHNP-C, BSN, MS
Authorized Official - Phone:419-559-5904
Mailing Address - Street 1:3772 N MOUNTAINOAK DR
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84310
Mailing Address - Country:US
Mailing Address - Phone:419-559-5904
Mailing Address - Fax:
Practice Address - Street 1:3772 N MOUNTAINOAK DR
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:UT
Practice Address - Zip Code:84310
Practice Address - Country:US
Practice Address - Phone:419-559-5904
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10115460-4405OtherNP LICENSURE
OHNP-07962OtherBON NP LICENSURE
UT363LW0102XOtherSECONDARY TAXONOMY
OH363LW0102XOtherPRIMARY TAXONOMY
I20180403001591OtherPECOS ENROLLMENT ID