Healthcare Provider Details

I. General information

NPI: 1235367517
Provider Name (Legal Business Name): SEAN R ENNIST RNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 VISTA DR
LARAMIE WY
82070-5530
US

IV. Provider business mailing address

1909 VISTA DR
LARAMIE WY
82070-5530
US

V. Phone/Fax

Practice location:
  • Phone: 307-745-8851
  • Fax: 307-742-0961
Mailing address:
  • Phone: 307-745-8851
  • Fax: 307-742-0961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number22491
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: