Provider Demographics
NPI:1548989650
Name:ENNIS, MELISSA CATHERINE (MSN, APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:CATHERINE
Last Name:ENNIS
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:CATHERINE
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1225 E LATHAM AVE STE B
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4423
Mailing Address - Country:US
Mailing Address - Phone:216-544-6857
Mailing Address - Fax:
Practice Address - Street 1:17612 17TH ST
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-1962
Practice Address - Country:US
Practice Address - Phone:216-544-6857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95160974163W00000X, 163WE0003X
CA95022314363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner