Healthcare Provider Details

I. General information

NPI: 1740246958
Provider Name (Legal Business Name): DIANA KIM ENNIS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 INDEPENDENCE DR.
COLUMBUS MS
39710-0001
US

IV. Provider business mailing address

8536 TIMBER WALK CV
CORDOVA TN
38018-4337
US

V. Phone/Fax

Practice location:
  • Phone: 662-434-2181
  • Fax:
Mailing address:
  • Phone: 901-755-3599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License NumberAPN0000006307
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: