Provider Demographics
NPI:1285852913
Name:ENNALS, DAVITA MICHELLE (CNA)
Entity Type:Individual
Prefix:
First Name:DAVITA
Middle Name:MICHELLE
Last Name:ENNALS
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 E LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08260-6107
Mailing Address - Country:US
Mailing Address - Phone:609-553-0714
Mailing Address - Fax:
Practice Address - Street 1:261 CONNECTICUT DR
Practice Address - Street 2:SUITE 5
Practice Address - City:BURLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08016-4177
Practice Address - Country:US
Practice Address - Phone:800-950-6066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNA8116134376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide