Provider Demographics
NPI:1194273565
Name:ENIS, AMY LUCKETT (PMHNP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LUCKETT
Last Name:ENIS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5206 FOUNDERS WAY CT
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77091-5654
Mailing Address - Country:US
Mailing Address - Phone:662-645-2386
Mailing Address - Fax:
Practice Address - Street 1:12011 SAN VICENTE BLVD STE 305A
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-4944
Practice Address - Country:US
Practice Address - Phone:747-212-3876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP141672363LP0808X
WAAP61413619363LP0808X
CA95007447363LP0808X
MS901683363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00026834Medicaid
MS541979YJ5DMedicare PIN