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General NPI Number Information
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NPI Number | 1063733376
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Entity Type | Individual
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Provider Name | ELIZABETH MARGARET ENNIS PA-C
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Gender | Female
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Dates
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Enumeration Date | 06/21/2010
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Last Update Date | 11/18/2022
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Provider Practice Location Address
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Address Line | 550 POPE AVE NW STE 200
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City | WINTER HAVEN
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State | FL
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Zip | 33881-4679
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Country | US
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Telephone | 863-299-2630
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Fax |
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Provider Business Mailing Address
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Address Line | 5536 ANSLEY WAY
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City | MOUNT DORA
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State | FL
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Zip | 32757-8000
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Country | US
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Telephone | 352-400-8457
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA 9105563
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License Number State | FL
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