Provider Demographics
NPI:1447681275
Name:ENNIS, TIFANI VERONICA
Entity type:Individual
Prefix:
First Name:TIFANI
Middle Name:VERONICA
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 1:208 S FRONT ST
Mailing Address - Street 2:
Mailing Address - City:WRIGHTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17368-1613
Mailing Address - Country:US
Mailing Address - Phone:717-332-6026
Mailing Address - Fax:
Practice Address - Street 1:50 WYNTRE BROOKE DR
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-4535
Practice Address - Country:US
Practice Address - Phone:717-812-5626
Practice Address - Fax:717-741-0879
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-04
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG005993171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor