Ennis, Tara Rexanne

Ennis, Tara Rexanne is an sole proprietor health care provider with primary practice located at 1042 Mar Walt Dr , Fort Walton Beach FL 32547-6645. She recently has 2 registered licenses in different health care specialties including Other Service Providers / Specialist, Allopathic & Osteopathic Physicians / Surgery. Allopathic & Osteopathic Physicians / Surgery is her primary health care specialty. Ennis, Tara Rexanne can be contacted via phone (850) 863-0400.

Contact Information

Primary practice address
1042 Mar Walt Dr Fort Walton Beach FL 32547-6645
Phone: (850) 863-0400
Fax: (850) 863-0417
Website:
Map and Directions

Health care specialties

SpecialtyCodeLicense #State
Other Service Providers / Specialist 174400000X 28214 Alabama
Allopathic & Osteopathic Physicians / Surgery 208600000X ME121048 Florida

Profile Details

NPI number 1700961141
LBN Legal business name Ennis, Tara Rexanne
Credentials Doctor of Medicine (MD)
Entity Individual
Sole proprietor 1 Yes
Enumeration date Oct 26th, 2006
Last updated Jul 7th, 2021 - about 3 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1700961141 NPPES
Alabama MEDICAID 120202
Alabama Other 102I028400

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