Provider Demographics
NPI:1083814222
Name:ENSLEY, DEIRDRE W (FNP, BC)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:W
Last Name:ENSLEY
Suffix:
Gender:F
Credentials:FNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2918 E WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30721-8724
Mailing Address - Country:US
Mailing Address - Phone:706-529-4600
Mailing Address - Fax:706-529-4633
Practice Address - Street 1:2918 E WALNUT AVE
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30721-8724
Practice Address - Country:US
Practice Address - Phone:706-529-4600
Practice Address - Fax:706-529-4633
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN077047363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0008787996NMedicaid