Provider Demographics
NPI:1760691398
Name:ENNIS, PATRICIA ANN (RD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:ENNIS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2390 PEACOCK VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91915-2186
Mailing Address - Country:US
Mailing Address - Phone:619-941-2510
Mailing Address - Fax:
Practice Address - Street 1:751 MEDICAL CENTER CT
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6617
Practice Address - Country:US
Practice Address - Phone:619-482-3480
Practice Address - Fax:619-482-3644
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered