Provider Demographics
NPI:1023816501
Name:TAD-AWAN, ENNEMAN IRENE (NP)
Entity type:Individual
Prefix:
First Name:ENNEMAN IRENE
Middle Name:
Last Name:TAD-AWAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:683 ASH AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-5338
Mailing Address - Country:US
Mailing Address - Phone:417-860-9671
Mailing Address - Fax:
Practice Address - Street 1:1173 FRONT ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-3904
Practice Address - Country:US
Practice Address - Phone:619-409-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029080363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner