Provider Demographics
NPI:1962041400
Name:PELLETIER-THEISEN, KELISE
Entity Type:Individual
Prefix:
First Name:KELISE
Middle Name:
Last Name:PELLETIER-THEISEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1946 5TH CT
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-5425
Mailing Address - Country:US
Mailing Address - Phone:773-453-3531
Mailing Address - Fax:
Practice Address - Street 1:1946 5TH CT
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-5425
Practice Address - Country:US
Practice Address - Phone:772-453-3531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-01
Last Update Date:2020-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula