Healthcare Provider Details

I. General information

NPI: 1871577759
Provider Name (Legal Business Name): LISA KIMBERLY ENNIS PT MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2005
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26755 JEFFERSON AVE STE D-1
MURRIETA CA
92562-8924
US

IV. Provider business mailing address

23100 EUCALYPTUS AVE STE C
MORENO VALLEY CA
92553-5439
US

V. Phone/Fax

Practice location:
  • Phone: 951-574-6300
  • Fax: 951-574-6301
Mailing address:
  • Phone: 951-660-4532
  • Fax: 951-379-1501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT22506
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: