Provider Demographics
NPI:1548086614
Name:HEADLEY, ELISE KAI (DOM)
Entity type:Individual
Prefix:DR
First Name:ELISE
Middle Name:KAI
Last Name:HEADLEY
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 OAKLEY LN APT A
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-4482
Mailing Address - Country:US
Mailing Address - Phone:505-930-4104
Mailing Address - Fax:
Practice Address - Street 1:131 OAKLEY LN APT A
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-4482
Practice Address - Country:US
Practice Address - Phone:505-930-4104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-22
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDOM23002171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist