Provider Demographics
NPI:1487041026
Name:MCENNIS, EBONY NICOLE
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:NICOLE
Last Name:MCENNIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15395 SHEILA ST
Mailing Address - Street 2:APARTMENT A
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92551-4551
Mailing Address - Country:US
Mailing Address - Phone:951-488-4726
Mailing Address - Fax:
Practice Address - Street 1:1950 S SUNWEST LN
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3258
Practice Address - Country:US
Practice Address - Phone:909-252-4010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program