Provider Demographics
NPI:1164625208
Name:ENNIS, DONNA SHEPHERD (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:SHEPHERD
Last Name:ENNIS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4485 FURLING LN
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-5331
Mailing Address - Country:US
Mailing Address - Phone:850-974-9545
Mailing Address - Fax:
Practice Address - Street 1:21 W MAIN AVE
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32435-2529
Practice Address - Country:US
Practice Address - Phone:850-892-7332
Practice Address - Fax:850-892-2405
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9200638363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily