Healthcare Provider Details

I. General information

NPI: 1346241288
Provider Name (Legal Business Name): MICHAEL P ENNIS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FOGG RD
WEYMOUTH MA
02190-2432
US

IV. Provider business mailing address

3645 SLAYTON AVE
NORTH PORT FL
34286-4211
US

V. Phone/Fax

Practice location:
  • Phone: 781-624-8000
  • Fax:
Mailing address:
  • Phone: 401-486-8969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number213881
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number11011995
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: