Provider Demographics
NPI:1124843503
Name:ENNIN, PHILIP MIRACLE JR (APRN)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:MIRACLE
Last Name:ENNIN
Suffix:JR
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 GORDON LN
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06118-2222
Mailing Address - Country:US
Mailing Address - Phone:860-655-2432
Mailing Address - Fax:
Practice Address - Street 1:269 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062-1335
Practice Address - Country:US
Practice Address - Phone:860-655-2432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-20
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT164301163W00000X
CT14447363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse