MEDICARE: KRISTEN ENNIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	1798213241	NY

General Provider Information

NPI Number	:	1144171687
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN ENNIS

Provider Business Mailing Address
First Line	:	159 TANGLEWOOD DR
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10308-1854
Country	:	US
Telephone Number	:	718-490-3754
Fax Number	:

Provider Business Practice Location Address
First Line	:	159 TANGLEWOOD DR
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10308-1854
Country	:	US
Telephone Number	:	718-490-3754
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2026
Last Update Date	:	02/09/2026

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Directions to “ KRISTEN ENNIS ” Practice Location

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