Provider Demographics
NPI:1134362817
Name:ERNEST, NOLA JEAN (MD, PHD)
Entity type:Individual
Prefix:
First Name:NOLA
Middle Name:JEAN
Last Name:ERNEST
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 CLINIC DR
Mailing Address - Street 2:DOTHAN PEDIATRIC CLINIC
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-1980
Mailing Address - Country:US
Mailing Address - Phone:334-793-1881
Mailing Address - Fax:334-712-1815
Practice Address - Street 1:526 BOLL WEEVIL CIR
Practice Address - Street 2:ENTERPRISE PEDIATRIC CLINIC
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-4012
Practice Address - Country:US
Practice Address - Phone:334-308-1166
Practice Address - Fax:334-308-1019
Is Sole Proprietor?:No
Enumeration Date:2009-04-11
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL31586208000000X
ALMD.3605208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL184547Medicaid