Provider Demographics
NPI:1710511647
Name:ENNIS, ALEXANDRA NICOLE (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:NICOLE
Last Name:ENNIS
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:ALLIE
Other - Middle Name:
Other - Last Name:ENNIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, RD, LD
Mailing Address - Street 1:12840 FAIRHILL RD APT 24
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-1227
Mailing Address - Country:US
Mailing Address - Phone:812-887-5469
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:812-887-1202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-29
Last Update Date:2020-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.08752133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered