Provider Demographics
NPI:1518784511
Name:ENNS, NATHANAEL (PHD, BCDMO)
Entity type:Individual
Prefix:DR
First Name:NATHANAEL
Middle Name:
Last Name:ENNS
Suffix:
Gender:M
Credentials:PHD, BCDMO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 BLUE CYPRESS DR
Mailing Address - Street 2:
Mailing Address - City:GROVELAND
Mailing Address - State:FL
Mailing Address - Zip Code:34736-8110
Mailing Address - Country:US
Mailing Address - Phone:352-888-4045
Mailing Address - Fax:
Practice Address - Street 1:835 7TH ST STE 1
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-2190
Practice Address - Country:US
Practice Address - Phone:352-901-4513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLEHP1193225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner