Provider Demographics
NPI:1265425185
Name:ENNIS, CHERYL A (MD)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:A
Last Name:ENNIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110A CONCORD ST
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03064-1704
Mailing Address - Country:US
Mailing Address - Phone:603-889-3249
Mailing Address - Fax:
Practice Address - Street 1:295 VARNUM AVE
Practice Address - Street 2:LOWELL GENERAL HOSPITAL
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854
Practice Address - Country:US
Practice Address - Phone:978-937-6889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH10783207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
22542240OtherTRICARE/CHAMPUS
NH01Y002477NH01OtherBC/BS
24483OtherCIGNA
NH30204275Medicaid
351677OtherHARVARD HEALTH
079963OtherTUFTS
783909OtherMVP
351677OtherHARVARD HEALTH
NHRE6059Medicare ID - Type Unspecified