Provider Demographics
NPI:1659925717
Name:ENNIS, NICOLE RENEE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:ENNIS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FLYFOOT DR
Mailing Address - Street 2:
Mailing Address - City:STEPHENSON
Mailing Address - State:VA
Mailing Address - Zip Code:22656-1955
Mailing Address - Country:US
Mailing Address - Phone:304-670-6877
Mailing Address - Fax:
Practice Address - Street 1:300 KELLY RD
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8099
Practice Address - Country:US
Practice Address - Phone:910-420-0226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-27
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024179001363LP0808X
NC5017739363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health