Provider Demographics
NPI:1992763890
Name:ENOCH, KIZZIE IDELLA
Entity type:Individual
Prefix:
First Name:KIZZIE
Middle Name:IDELLA
Last Name:ENOCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-4171
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 BIRCH ST
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-4171
Practice Address - Country:US
Practice Address - Phone:770-367-5357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA910718164X00000X
GALPN078944164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse