Provider Demographics
NPI:1245353416
Name:MAURIC, KELLI KEMENAH (WHNP-BC, APRN)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:KEMENAH
Last Name:MAURIC
Suffix:
Gender:F
Credentials:WHNP-BC, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:801-710-2825
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:801-710-2825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-07962363LW0102X
UT10115460-4405363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0827627Medicaid
UT10115460-4405OtherAPRN STATE LICENSURE
OHNP-07962OtherOHIO BOARD OF NURSING - CERTIFICATE OF AUTHORITY FOR WHNP-BC LICENSURE - OH
OH000000356173OtherANTHEM B/C B/S
UT193200000XOtherMULTI-SPECIALTY GROUP TAXONOMY BALANCE THE BRAIN PROFESSIONAL CORPORATION
UT363LW0102XOtherNURSE PRACTITIONER - WOMENS HEALTH TAXONOMY
OHMAU1-0427-9585OtherNATIONAL CERTIFICATION CORPORATION -USA WOMENS HEALTH NURSE PRACTITIONER WHNP-BC
UT1073270666OtherNPI BALANCE THE BRAIN PROFESSIONAL CORPORATION
UT193200000XOtherPROVIDER MULTI-SPECIALTY GROUP - SECONDARY TAXONOMY BALANCE THE BRAIN PROF CORP
OH356173OtherBUCKEYE
I20180403001591OtherPECOS ENROLLMENT ID
OHR04778OtherSUMMACARE
UT10115460-8900OtherAPRN CONTROLLED SUBSTANCE ID
104279585OtherNATIONAL CERTIFICATION CORPORATION - WHNP-BC (BOARD CERTIFIED)
UTAPP0002758OtherCOPIC RRG VIA BAXTER & ASSOCIATES LLC CERTIFICATE OF LIABILITY INSURANCE
OHP01571485OtherMEDICARE RR
OHRN266333OtherNATIONAL COUNCIL OF NURSING STATE BOARDS & LICENSURE REGISTERED NURSES
OH740142OtherBUCKEYE MEDICAID
OHAPRN.CNP.07962OtherWHNP-BC WITH CERTIFICATE TO PRESCRIBE