Healthcare Provider Details

I. General information

NPI: 1114880093
Provider Name (Legal Business Name): MICHELLE KN ENNIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3960 GREENSIDE CT
DACULA GA
30019-4594
US

IV. Provider business mailing address

3960 GREENSIDE CT
DACULA GA
30019-4594
US

V. Phone/Fax

Practice location:
  • Phone: 678-469-2872
  • Fax:
Mailing address:
  • Phone: 678-469-2872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number11718
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: