Provider Demographics
NPI:1972173359
Name:RAU, KELSI MARIE (RN, NP)
Entity Type:Individual
Prefix:
First Name:KELSI
Middle Name:MARIE
Last Name:RAU
Suffix:
Gender:F
Credentials:RN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 PETERBOROUGH ST APT 14
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-4212
Mailing Address - Country:US
Mailing Address - Phone:904-238-5215
Mailing Address - Fax:
Practice Address - Street 1:1424 MADERA RD
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-3053
Practice Address - Country:US
Practice Address - Phone:805-522-5722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-29
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2346727163W00000X, 363L00000X
CA95028896363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse