Basic Information
| Provider Information | |||||||||
| NPI: | 1568626653 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ENNIS | ||||||||
| FirstName: | KRISTIE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | PHYSICIANS ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 BILLINGSLEY RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282111075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043727974 | ||||||||
| FaxNumber: | 7043725166 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 BILLINGSLEY RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282111075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043727974 | ||||||||
| FaxNumber: | 7043725166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2008 | ||||||||
| LastUpdateDate: | 02/28/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-01439 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.