MEDICARE: MRS. NEVA GAIL ENNIS RN

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	163W00000X	Registered Nurse	0000047239	TN

General Provider Information

NPI Number	:	1689861767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NEVA GAIL ENNIS RN

Provider Business Mailing Address
First Line	:	592 SUMMERVILLE RD
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37663-3100
Country	:	US
Telephone Number	:	423-239-7681
Fax Number	:

Provider Business Practice Location Address
First Line	:	592 SUMMERVILLE RD
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37663-3100
Country	:	US
Telephone Number	:	423-239-7681
Fax Number	:

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

Provider Enumeration Date	:	10/02/2007
Last Update Date	:	10/02/2007

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