Provider Demographics
NPI:1447073937
Name:ENNIS, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ENNIS
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 1:8379 PINEY ORCHARD PKWY STE F
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-1508
Mailing Address - Country:US
Mailing Address - Phone:410-305-0601
Mailing Address - Fax:
Practice Address - Street 1:8379 PINEY ORCHARD PKWY STE F
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1508
Practice Address - Country:US
Practice Address - Phone:410-305-0601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD5994174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist