Healthcare Provider Details

I. General information

NPI: 1336842319
Provider Name (Legal Business Name): MRS. MARY ANGEL ENSLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2347 ROSSVILLE BLVD
CHATTANOOGA TN
37408-2250
US

IV. Provider business mailing address

2347 ROSSVILLE BLVD
CHATTANOOGA TN
37408-2250
US

V. Phone/Fax

Practice location:
  • Phone: 423-509-0763
  • Fax:
Mailing address:
  • Phone: 423-509-0763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN0000070781
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: