Provider Demographics
NPI:1649707779
Name:ENNIS, DANETTA MICHELLE (MS, ATC, LAT)
Entity type:Individual
Prefix:MRS
First Name:DANETTA
Middle Name:MICHELLE
Last Name:ENNIS
Suffix:
Gender:F
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 E MATTHEWS AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4362
Mailing Address - Country:US
Mailing Address - Phone:870-932-1820
Mailing Address - Fax:870-972-6712
Practice Address - Street 1:1416 E MATTHEWS AVE STE 200
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4362
Practice Address - Country:US
Practice Address - Phone:870-932-1820
Practice Address - Fax:870-972-6712
Is Sole Proprietor?:No
Enumeration Date:2017-05-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer