Provider Demographics
NPI:1376890053
Name:ENNIS, KIMBERLY ROSE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ROSE
Last Name:ENNIS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ROSE
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3317 N WIMBERLY DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4056
Mailing Address - Country:US
Mailing Address - Phone:479-587-3117
Mailing Address - Fax:
Practice Address - Street 1:3317 N WIMBERLY DR
Practice Address - Street 2:2ND FLOOR
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4056
Practice Address - Country:US
Practice Address - Phone:479-587-3117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12216702251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic