Healthcare Provider Details

I. General information

NPI: 1750290425
Provider Name (Legal Business Name): ANN T ENYOBI PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3646 STUBAI TRL
ROCKFORD IL
61114-7335
US

IV. Provider business mailing address

3646 STUBAI TRL
ROCKFORD IL
61114-7335
US

V. Phone/Fax

Practice location:
  • Phone: 214-991-0101
  • Fax:
Mailing address:
  • Phone: 214-991-0101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number19049-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: