Provider Demographics
NPI:1972314813
Name:ENNISON, SAMMY
Entity type:Individual
Prefix:
First Name:SAMMY
Middle Name:
Last Name:ENNISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4315 MULBERRY RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:HOSCHTON
Mailing Address - State:GA
Mailing Address - Zip Code:30548-1699
Mailing Address - Country:US
Mailing Address - Phone:470-257-2672
Mailing Address - Fax:
Practice Address - Street 1:4315 MULBERRY RIDGE LN
Practice Address - Street 2:
Practice Address - City:HOSCHTON
Practice Address - State:GA
Practice Address - Zip Code:30548-1699
Practice Address - Country:US
Practice Address - Phone:470-257-2672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-20
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Multi-Specialty