MEDICARE: MRS. DIANA KIM ENNIS NP

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	163WW0101X	Ambulatory Women's Health Care Registered Nurse	APN0000006307	TN

General Provider Information

NPI Number	:	1740246958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DIANA KIM ENNIS NP

Provider Business Mailing Address
First Line	:	8536 TIMBER WALK CV
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38018-4337
Country	:	US
Telephone Number	:	901-755-3599
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 INDEPENDENCE DR.
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39710-0001
Country	:	US
Telephone Number	:	662-434-2181
Fax Number	:

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

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	07/08/2007

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