MEDICARE: KIMBERLY 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	225100000X	Physical Therapist	PT0390	MS

General Provider Information

NPI Number	:	1750662078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY ENNIS

Provider Business Mailing Address
First Line	:	719 CLINTON PKWY
Second Line	:	STE B
City	:	CLINTON
State	:	MS
Zip	:	39056-5245
Country	:	US
Telephone Number	:	601-924-7828
Fax Number	:

Provider Business Practice Location Address
First Line	:	719 CLINTON PKWY
Second Line	:	STE B
City	:	CLINTON
State	:	MS
Zip	:	39056-5245
Country	:	US
Telephone Number	:	601-924-7828
Fax Number	:

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

Provider Enumeration Date	:	08/31/2011
Last Update Date	:	07/08/2016

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Directions to “ KIMBERLY ENNIS ” Practice Location

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