Provider Demographics
NPI:1700961141
Name:ENNIS, TARA REXANNE (MD)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:REXANNE
Last Name:ENNIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:REXANNE
Other - Last Name:HARDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1775 LEWIS TURNER BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1267
Mailing Address - Country:US
Mailing Address - Phone:850-863-0400
Mailing Address - Fax:850-863-0417
Practice Address - Street 1:1042 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6645
Practice Address - Country:US
Practice Address - Phone:850-863-0400
Practice Address - Fax:850-863-0417
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL28214174400000X
FLME121048208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL120202Medicaid
102I028400OtherM'CARE PROVIDER #
AL120202Medicaid