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General NPI Number Information
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NPI Number | 1700961141
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Entity Type | Individual
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Provider Name | TARA REXANNE ENNIS MD
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Gender | Female
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Dates
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Enumeration Date | 10/26/2006
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Last Update Date | 07/07/2021
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Provider Practice Location Address
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Address Line | 1042 MAR WALT DR
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-6645
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Country | US
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Telephone | 850-863-0400
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Fax | 850-863-0417
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Provider Business Mailing Address
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Address Line | 1775 LEWIS TURNER BLVD SUITE 101
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-1267
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Country | US
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Telephone | 850-863-0400
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Fax | 850-863-0417
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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 | 174400000X
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Taxonomy Name | Specialist
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License Number | 28214
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License Number State | AL
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | ME121048
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License Number State | FL
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