Healthcare Provider Details

I. General information

NPI: 1962571612
Provider Name (Legal Business Name): NADINE ANGELA ENNIS P.A.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 09/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 MARTIN LUTHER KING JR DR SW
ATLANTA GA
30331-3711
US

IV. Provider business mailing address

3620 MARTIN LUTHER KING JR DR SW
ATLANTA GA
30331-3711
US

V. Phone/Fax

Practice location:
  • Phone: 404-696-7300
  • Fax: 404-699-3514
Mailing address:
  • Phone: 404-696-7300
  • Fax: 404-699-3514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004493
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: