Provider Demographics
NPI:1871577759
Name:ENNIS, LISA KIMBERLY (PT MPT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:KIMBERLY
Last Name:ENNIS
Suffix:
Gender:F
Credentials:PT MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23100 EUCALYPTUS AVE STE C
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-5439
Mailing Address - Country:US
Mailing Address - Phone:951-660-4532
Mailing Address - Fax:
Practice Address - Street 1:23100 EUCALYPTUS AVE STE C
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-5439
Practice Address - Country:US
Practice Address - Phone:951-379-1500
Practice Address - Fax:951-379-1501
Is Sole Proprietor?:No
Enumeration Date:2005-12-03
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT22506225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA155479Medicare PIN
CACA155477Medicare PIN