Provider Demographics
NPI:1063733376
Name:ENNIS, ELIZABETH MARGARET (PA-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARGARET
Last Name:ENNIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5536 ANSLEY WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-8000
Mailing Address - Country:US
Mailing Address - Phone:352-400-8457
Mailing Address - Fax:
Practice Address - Street 1:550 POPE AVE NW STE 200
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4679
Practice Address - Country:US
Practice Address - Phone:863-299-2630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9105563363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA-9105563OtherDEPARTMENT OF HEALTH
FL002747500Medicaid
1780221774OtherNRCME
FL342264OtherAVMED
FLPAX 0008401OtherDOH PRESCRIBING
FLYO5FROtherBCBS
FLPA-9105563OtherDEPARTMENT OF HEALTH
FLPAX 0008401OtherDOH PRESCRIBING