Provider Demographics
NPI:1104456235
Name:INGRAM, LISA GAYE (MSN, APRN, FNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:GAYE
Last Name:INGRAM
Suffix:
Gender:F
Credentials:MSN, APRN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1059
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-0027
Mailing Address - Country:US
Mailing Address - Phone:706-647-8111
Mailing Address - Fax:706-646-3153
Practice Address - Street 1:801 W GORDON ST
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-3426
Practice Address - Country:US
Practice Address - Phone:706-647-8111
Practice Address - Fax:706-646-3153
Is Sole Proprietor?:No
Enumeration Date:2020-01-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN062064363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner