Provider Demographics
NPI:1962571612
Name:ENNIS, NADINE ANGELA (PAC)
Entity type:Individual
Prefix:MS
First Name:NADINE
Middle Name:ANGELA
Last Name:ENNIS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 MARTIN LUTHER KING JR DR SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-3711
Mailing Address - Country:US
Mailing Address - Phone:404-696-7300
Mailing Address - Fax:404-699-3514
Practice Address - Street 1:3620 MARTIN LUTHER KING JR DR SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-3711
Practice Address - Country:US
Practice Address - Phone:404-696-7300
Practice Address - Fax:404-699-3514
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004493363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA457877647AMedicaid
GA457877647CMedicaid
GA457877647DMedicaid
GA457877647BMedicaid
GA457877647EMedicaid
GA457877647CMedicaid
GA457877647EMedicaid