Healthcare Provider Details

I. General information

NPI: 1225385644
Provider Name (Legal Business Name): HEIDI NICOLE ENSLEY O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2012
Last Update Date: 08/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2508 EDGEMONT DR STE 6
ARKANSAS CITY KS
67005-3854
US

IV. Provider business mailing address

2508 EDGEMONT DR STE 6
ARKANSAS CITY KS
67005-3854
US

V. Phone/Fax

Practice location:
  • Phone: 620-442-2577
  • Fax: 620-442-2578
Mailing address:
  • Phone: 620-442-2577
  • Fax: 620-442-2578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1916
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: