Provider Demographics
NPI:1063056323
Name:INGRAM, SANDRA LYNN
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LYNN
Last Name:INGRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:LYNN
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P O BOX 2823
Mailing Address - Street 2:
Mailing Address - City:BANDERA
Mailing Address - State:TX
Mailing Address - Zip Code:78003
Mailing Address - Country:US
Mailing Address - Phone:210-843-2648
Mailing Address - Fax:
Practice Address - Street 1:810 LACEY DRIVE
Practice Address - Street 2:
Practice Address - City:BANDERA
Practice Address - State:TX
Practice Address - Zip Code:78003
Practice Address - Country:US
Practice Address - Phone:830-688-1749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X, 376K00000X
TXNA066636923747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide