Provider Demographics
NPI:1962476721
Name:ENNIS, BETH LENOR (APN, BC)
Entity Type:Individual
Prefix:MRS
First Name:BETH
Middle Name:LENOR
Last Name:ENNIS
Suffix:
Gender:F
Credentials:APN, BC
Other - Prefix:MRS
Other - First Name:BETH
Other - Middle Name:WATERS
Other - Last Name:ENNIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APN, BC
Mailing Address - Street 1:PO BOX 409
Mailing Address - Street 2:1 FRANKEE ST.
Mailing Address - City:TONOPAH
Mailing Address - State:NV
Mailing Address - Zip Code:89049-0409
Mailing Address - Country:US
Mailing Address - Phone:775-482-6659
Mailing Address - Fax:775-482-3430
Practice Address - Street 1:1 FRANKEE ST
Practice Address - Street 2:
Practice Address - City:TONOPAH
Practice Address - State:NV
Practice Address - Zip Code:89049-0409
Practice Address - Country:US
Practice Address - Phone:775-482-6659
Practice Address - Fax:775-482-3430
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV27437/APN00428363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV24-12021Medicaid
NV24-12021Medicaid