=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962571612
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NADINE ANGELA ENNIS P.A.C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2006
-----------------------------------------------------
Last Update Date | 09/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3620 MARTIN LUTHER KING JR DR SW
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30331-3711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-696-7300
-----------------------------------------------------
Fax | 404-699-3514
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3620 MARTIN LUTHER KING JR DR SW
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30331-3711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-696-7300
-----------------------------------------------------
Fax | 404-699-3514
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 004493
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------