Provider Demographics
NPI:1750417358
Name:ENNIS, KATHLEEN A (APRN, DNPC)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:ENNIS
Suffix:
Gender:F
Credentials:APRN, DNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:COS COB
Mailing Address - State:CT
Mailing Address - Zip Code:06807-2403
Mailing Address - Country:US
Mailing Address - Phone:203-253-2225
Mailing Address - Fax:203-869-4421
Practice Address - Street 1:30 ORCHARD ST
Practice Address - Street 2:
Practice Address - City:COS COB
Practice Address - State:CT
Practice Address - Zip Code:06807-2403
Practice Address - Country:US
Practice Address - Phone:203-253-2225
Practice Address - Fax:203-869-4421
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001317363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT500000270Medicaid
D300042375Medicare PIN